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RD131  M192  Reclaiming  the  maime 


;laiming 
the  maimed 


MC-  KENZIE 


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RECLAIMING    THE    .MAIMED 


•The 


THE  MACMILLAN   COMPANY 

NEW  YORK   •    BOSTON    •    CHICAGO   -    DALLAS 
ATLANTA   •    SAN    FRANCISCO 

MACMILLAN   &  CO.,  Limited 

LONDON  •  BOMBAY  •  CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OF  CANADA,  Ltd. 

TORONTO 


Reclaiming  the  Maimed 

A    HANDBOOK 
OF    PHYSICAL    THERAPY 


BY 


R.    TAIT    McKENZIE,    M.D. 

MAJOR    R.  A.  M.  C,    PROFESSOR    OF    PHYSICAL   THERAPY 
UNIVERSITY    OF    PENNSYLVANIA 


ILLUSTRATED 


THE    MACMILLAN    COMPANY 
1918 

All  rights  reserved 


(^ 


Copyright,  1918, 
By  the  MACMILLAN  COMPANY. 

Set  up  and  electrotyped.     Published  May,  1918. 


'^1    \-J'/:_ 


WortDooU  prE00 

J.  S.  Cushing  Co.  —  Berwick  &  Smith  Co. 

Norwood,  Mass.,  U.S.A. 


CONTENTS 

PAGE 

Chapter  I  i 

Conditions  brought  about  by  the  present  war.  Cla[:s  of 
cases  capable  of  improvement  by  physical  means.  Plan- 
ning and  equipping  of  department  of  physical  therapy  in 
hospitals.     Recording  of  cases. 

Chapter  II lo 

Medical  electricity.  The  use  of  galvanism  and  ionization 
in  wounds  and  scar  tissue. 

Chapter  III 23 

The  faradic  current  and  high  frequency.  Muscle  testing 
and  exercising. 

Chapter  IV 37 

Radiant  heat  and  light;    their  uses  in  a  military'  hospital. 

Chapter  V 45 

Hydro-therapy,  The  Whirlpool  Bath  and  other  forms  of 
treatment. 

Chapter  VI 54 

Massage.  Its  technique  and  place  in  treatment.  Passive 
movement.     Its  place  and  limitations  in  contracted  joints. 

Chapter  VII 65 

Reeducation.  A  description  of  twenty  appliances  for 
the  reeducation  of  the  weakened  muscles  and  stiff  joints,  as 
designed  for,  and  adopted  by,  the  Military  Hospitals  Com- 
mission of  Canada.     (This  is  the  first  description  published.) 

Chapter  VIII 92 

Gymnastics  and  athletic  games.  Their  place  in,  and 
progressive  course  of,  reeducating  the  disabled  man, 

V 


vi  CONTENTS 

PAGE 

Chapter  IX 105 

Treatment  by  occupation.  Importance  of  occupation 
to  prevent  the  "hospital  habit."  Forms  of  occupation 
taught.     The  placing  of  men  in  civil  life,  after  recovery. 

Chapter  X  117 

Masking  of  facial  deformity.  The  construction  of  metal 
masks  to  enable  disfigured  men  to  occupy  positions,  without 
attracting  attention  to  their  disfigurement. 


INTRODUCTION 

In  the  following  pages  I  have  endeavored  to  put  in  small 
compass  a  description  of  the  means  that  have  been  potent 
in  putting  back  into  active  military  service  nearly  half  of 
those  men  wounded  or  otherwise  disabled  in  action,  who 
had  climbed  with  decreasing  speed  the  uphill  road  to  re- 
covery that  too  often  halts  at  permanent  invalidism. 

This  work  is  founded  on  an  experience  of  over  a  year  as 
Medical  Officer,  in  charge  of  the  "Command  Depot"  at 
Heaton  Park,  Manchester,  and  as  Inspector  of  similar  in- 
stitutions for  the  treatment  of  convalescents,  founded  by 
the  War  Office  throughout  the  British  Isles.  This  experience 
was  added  to  by  a  tour  of  inspection  of  the  Canadian  Con- 
valescent Hospitals,  established  by  the  Military  Hospitals 
Commission,  for  the  purpose  of  standardizing  the  teaching 
and  practice  of  physical  therapy. 

My  thanks  are  due,  and  gladly  given,  to  Sir  Alfred  Keogh, 
G.C.B.,  Director  General  of  Medical  Services,  whose  fore- 
sight and  energy  made  this  work  possible  in  Britain  and 
whose  sympathetic  support  helped  it  over  the  difficult  stages 
of  organization,  to  proved  efficiency.  To  the  practical 
common  sense  and  unbounded  activity  of  Sir  Robert  Jones, 
K.C.B.,  Inspector  of  Military  Orthopedics,  who  founded 
the  chain  of  orthopedic  centers,  to  which  curative  work- 
shops are  attached,  I  owe  much,  received  during  our  associa- 
tion in  the  inspection  of  hospitals  and  camps.  To  Doctor 
R.  Fortesque  Fox  I  am  indebted  for  assistance  in  establish- 
ing the  Hydro  at  Heaton  Park.  I  wish  to  thank  Captain 
A.  E.  Barclay,  R.A.M.C.,  for  invaluable  help  on  the  first 
appliances  used  for  reeducation  at  Heaton  Park,  of  which 

vii 


viii  INTRODUC  TION 

more  than  thirty  sets  have  already  been  distributed  through- 
out Great  Britain  and  India,  and  also  my  assistants,  Doctor 
H.  S.  Seeuwen,  and  Doctor  Frank  Radcliffe,  for  loyal  and 
efficient  service  at  all  times. 

To  Sir  James  Lougheed,  K.C.M.G.,  President  of  the 
Military  Hospitals  Commission,  now  the  Invahded  Soldiers' 
Commission,  who  showed  his  appreciation  of  the  importance 
of  physical  therapy  by  ordering  an  inspection  and  report  on 
the  subject,  I  owe  the  opportunity  of  studying  the  con- 
ditions in  the  Canadian  Military  Hospitals,  and  also  to  the 
Superintendent,  Colonel  Alfred  Thompson,  M.P.,  C.A.M.C, 
and  to  the  Director,  Mr.  S.  A.  Armstrong,  I  am  a  willing 
debtor  for  many  services  cheerfully  rendered. 

I  cannot  close  without  reference  to  the  experimental  work 
of  E.  A.  Bott,  Ph.D.,  and  his  staff  at  the  reeducation  center. 
Hart  House,  University  of  Toronto.  Many  of  the  standard 
appliances  adopted  by  the  Military  Hospitals  Commission 
for  the  reeducation  of  disabled  muscles  owe  much  to  their 
study  and  suggestions. 


RECLAIMING   THE    MAIMED 


RECLAIMING  THE  MAIMED 


CHAPTER  I 

The  calamity  of  war  has  been  necessary  to  startle  the  pro- 
fession into  a  realization  of  the  wide  field  that  should  be 
occupied  by  physical  methods  in  the  treatment  of  disease. 
The  sporadic  wounds  that  peaceful  life  produced  have  been 
multiplied  in  our  military  hospitals  into  groups,  the  excep- 
tion has  become  the  ordinary;  torn  and  mangled  bodies 
have  had  to  be  patched  and  remade,  and  functions  lost  or 
weakened  gradually  coaxed  back  toward  the  normal,  by 
means  hitherto  despised,  or  ignored  by  too  many  physicians 
and  surgeons. 

Until  the  outbreak  of  the  war  these  means  were  in  the 
hands  of  a  few  enthusiasts  in  the  profession,  or  were  exploited 
by  that  motley  army  of  camp  followers  who  had  entered  the 
highway  of  medical  practice,  not  by  the  gate,  but  through 
holes  in  the  wall,  puffed  up  by  the  importance  of  partial 
knowledge,  or  making  fact  bow  to  some  preposterous  theory. 

Old  conditions  have  come  up  with  new  names,  and  new 
conditions  have  had  to  be  met  by  a  rearrangement  and 
application  of  old  means.  We  must  reconsider  at  this 
time  the  whole  field  of  physical  therapy  as  applied  to  and 
affected  by  the  great  war. 

This  Cinderella  of  the  therapeutic  family  may  be  said  to 
include  the  application  of  Electricity  in  its  many  forms, 
Radiant  Heat,  Water,  Hot  and  Cold,  Massage,  Passive  Move- 
ment, Muscular  Reeducation,  and  Gymnastic  Exercises. 


2  RECLAIMING  THE  MAIMED 

Application  of  Physical  Therapy.  —  i.  Injury  to  pe- 
ripheral nerves,  all  the  way  from  bruising  of  a  nerve  trunk 
to  its  destruction  and  restoration  by  surgical  means. 

These  cases  are  accompanied  by  weakness,  or  paralysis, 
muscular  wasting,  and  contractures.  They  are  treated  by  wet 
or  dr}'  heat  to  exalt  the  local  circulation,  support  in  proper 
position  by  splints  to  prevent  the  overstretching  of  weakened 


Fig.  I.  —  Bullet  wound  of  the  arm  followed  by  ulnar  paralysis 
with  wasting. 

muscles,  and  the  resultant  permanent  contraction  of  those  that 
are  unimpaired,  galvanic,  and  afterward  faradic,  stimulation 
to  the  affected  muscles,  massage  to  keep  up  or  improve  their 
nutrition,  passive  movement  to  prevent  contraction  and  limi- 
tation of  the  normal  range  of  the  joint,  progressive  active 
movement,  joint  by  joint,  to  bring  back  and  strengthen  volun- 
tary power ;  ending  with  gymnastic  and  vocational  training 
for  skill  to  fit  the  patient  to  take  his  place  in  civil  life  again. 


RECLAIMING  THE  MAIMED 


2.  Scar  tissue,  either  in  preparation  for,  or  after  operation. 
A  bullet  may  leave  a  small  entrance  scar,  but  its  course 
through  the  tissues 
may  leave  great 
areas  in  which  mus- 
cle, fascia,  tendon, 
nerve,  periosteum, 
and  skin  are  matted 
together  in  one 
confused,  distorted 
mass,  leaving  the 
limb  blue,  clammy, 
moist  with  con- 
tinual perspiration, 
and  so  painful  that 
the  patient  winces  at 
the  slightest  touch 
—  even  after  ampu- 
tations the  sensi- 
tive nerve  endings 
caught  in  the  scar  of   the  operation  are  among  the  most 

troublesome  conditions  of 
war  surgery. 

Such  wounds  are 
treated  by  the  warmth 
of  the  whirlpool  bath, 
which  in  twenty  minutes 
changes  the  cold  purple 
of  the  painful  hand  into 
a  warm  crimson,  and 
enables  the  masseur  to 
stroke,  knead,  and  move 
a  joint  in  a  way  that  no 
amount  of  persuasion  would  have  made  tolerable  with- 
out it. 


Fig.  2.  —  Bullet  wound  of  the  back.     Entrance  at 
first  dorsal  level ;  exit  at  seventh  dorsal. 


Fig.  3. 


-  Painful  stump  following  explo- 
sion of  hand  grenade. 


4  RECLAIMING   THE  MAIMED 

The  hastening  of  repair  in  these  scars  by  diathermy  and 
ionization  and  the  stretching  of  beginning  contractures  by 
careful  manipulation,  taking  care  to  avoid  the  breaking  down 
of  scar  tissue  in  course  of  organization,  are  among  the  triumphs 
of  these  methods. 


Fig.  4.  —  One  hundred  and  thirteen  wounds  from  the 
explosion  of  one  shell. 


RECLAIMING   THE   MAIMED  5 

3.  Old  septic  wounds,  long  since  healed,  are  frequently 
persistently  painful,  and  a  focus  of  infection  may  be  dis- 
covered. It  is  a  frequent  experience  to  find  part  of  a  long 
scar  become  painful,  then  red,  and  finally  to  see  a  sequestrum 
of  bone  extruded  that  would  have  lain  for  months  a  source  of 
trouble  without  the  stimulation  of  heat  and  massage  to 
hasten  its  removal.  Naturally  such  cases  need  most  careful 
supervision,  and  a  rough  and  unskilled  operator  may  easily 
do  more  harm  than  good.  Electricity,  heat,  and  massage 
have  a  most  important  place  in  softening  extensive  scar 
tissue  and  making  the  work  of  the  surgeon  easier. 

4.  In  all  post-operative  conditions,  the  cure  must  be 
completed  by  physical  means. 

It  is  not  enough  to  break  down  an  adhesion,  or  restore  a 
joint  to  potential  usefulness.  Its  nutrition  must  be  improved, 
and  the  patient  must  be  taught  to  use  it.  Even  if  it  is  pos- 
sible to  move  it  passively  throughout  its  whole  range,  the 
cure  is  not  complete  till  the  patient  can  do  this  himself  with 
power  and  skill.  He  must  be  taken  through  a  course  of  re- 
education beginning  with  simple  single  movements,  and 
advancing  to  those  harder  and  more  complex.  Devices  for 
this  purpose  must  be  designed  and  employed  until  he  can  go 
through  the  more  complicated  actions  of  the  craft  he  may 
elect  to  practice. 

5.  Functional  neuroses,  which  take  the  form  of  palsies, 
contractures,  loss  of  sight,  speech,  or  hearing,  areas  of 
anaesthesia  or  hypersesthesia,  show  many  dramatic  cures 
by  physical  means.  Contractures  slowly  stretched  and  kept 
in  place  by  splints,  systematically  massaged,  and  exercised 
by  the  faradic  battery,  where  voluntary  movement  cannot 
be  obtained,  can  be  brought  back  to  usefulness  by  a  com- 
bination of  hypnotism,  suggestion,  encouragement,  and  the 
gradual  replacing  of  them  by  voluntary  movement.  The 
operator  here  must  be  both  priest  and  physician,  for  the 
mental  is  even  more  important  than  the  physical  treatment, 


RECLAIMING   THE  MAIMED 


and  these  very  real  conditions,  beyond  the  patient's  cont 
in  most  cases,  require  persistent  and  intelHgent  treatme. 
sometimes  over  long  periods  of  time. 

6.   The   conditions   variously   grouped   under   the   nam 
''Shell  Shock,"  which  vary  all  the  way  from  minute  hemor- 
rhages into  the  brain  substance,  caused  by  concussion,  to 

fear  and  intolerable  weariness, 
must     be     treated     by     this 
means.      A  soldier  begins  to 
move  his  head  rhythmically, 
twitch  his  arm,  or  clutch  at 
the  sound  of  a  shell,  and  the 
regimental   surgeon,   if   he  is 
wise,  sends  him  back  to  the 
rest  camp  for  a  week  or  two. 
If  he  is  kept  until  the  inevi- 
table   smash    comes,    his   re- 
covery will   be   a   matter   of 
months   at    best,   and   he   is 
usually    out    of    commission 
permanently.    Tremors  coarse 
and  fine,  up  to  the  point  of 
a  general  convulsive  seizure, 
rhythmical  movements  when 
the   man    is   spoken   to   and 
calming  down  when  he  is  left 
alone,  are  characteristic. 
Many  of  them  are  martial  misfits,  never  built  for  the  noise 
and  stress  of  modern  warfare,  and  rapidly  going  to  pieces 
under  it,  with  a  history  of  nervousness  and  frequently  with 
enlarged   thyroids,  rapid   pulse,  and  prominent   eyes.     All 
these  conditions   call  for  rest   and   sedative   treatment,  at 
first   the   continuous   bath  at  skin  temperature,  an  hour's 
rest  in  bed  daily,  and  the  substitution  of  gentle  massage 
and  electricity  for  active  movement,  with  later  a  gradual 


Fig.  5.  —  Functional  paralysis  of  ab- 
dominal muscles  following  crush- 
ing injury  in  a  trench. 


RECLAIMING   THE  MAIMED  7 

crease  of  exercise  beginning  with  a  slow  walk,  and  ending 
ith  gymnastics,  games,  and  vocational  training. 

7.  The  "soldier's  heart"  is  but  a  manifestation  of  over- 
;5train.     The  rapid  pulse   and   breathlessness,  the  enlarged 

■thyroid,  all  show  the  nervous  origin  of  the  condition  so 
familiar  to  medical  officers  as  D.  A.  H.  In  these  cases  the 
faradic  or  high  frequency  current  through  the  thyroid,  the 
sedative  bath,  gentle  massage,  and  rest  quickly  reduce  the 
rapid  pulse  rate  and  allow  him  to  bear,  without  damage, 
an  increasing  load  of  work  in  the  form  of  light  gymnastic 
exercise  and  walking. 

8.  The  debilitated,  whether  from  typhoid  or  dysentery, 
are  built  up  again,  hardened,  and  made  ready  for  service  by 
graduated  exercises  of  effort  like  gymnastics,  and  of  endur- 
ance like  walking,  until  they  can  bear  the  load  of  work  to 
which  they  were  formerly  accustomed. 

9.  The  place  of  physical  remedies  in  the  treatment  of 
sprains  and  fractures,  in  rheumatism  and  gout,  in  fiat  foot 
and  other  postural  defects,  need  not  be  discussed  here. 
Enough  has  been  said  to  show  that  most  of  the  men  that 
fill  our  war  hospitals,  command  depots,  and  convalescent 
homes  must  depend  in  great  measure  for  their  present  treat- 
ment and  future  prospects  on  the  masseuse,  the  practitioner 
of  electro-  and  hydro-therapy,  the  physical  instructor,  and 
the  teacher  of  vocational  training. 

The  progress  of  treatment  usually  begins  with  prepara- 
tion by  heat,  either  wet,  dry,  or  produced  by  electricity,  on 
through  stimulation  of  nutrition,  by  massage,  and  passive 
movement,  then  to  simple  exercise  taken  voluntarily,  and 
finally  to  skilled  movements  by  gymnastics,  games,  and 
handcrafts. 

Cases  naturally  divide  themselves  into  two  classes,  those 
requiring  general  treatment  and  those  requiring  local  treat- 
ment ;  and  in  planning  a  Department  of  Physical  Therapy 
this  should  be  kept  in  mind. 


RECLAIMING  THE  MAIMED 


Fig.  6.  —  Plan  for  department  of  physical 
therapy  in  a  military  hospital  for  con- 
valescents. 


1.  By  general  treatment 
we  include  the  douche,  the 
full  bath,  the  cabinet  for 
light  and  heat  and  general 
massage.  For  all  these 
the  patient  must  undress 
and  after  them  he  should 
rest.  Make  ample  pro- 
vision for  a  waiting  and 
dressing  room  with  linen 
closet  and  blanket  warmer. 
A  patient  with  irregular, 
irritable  heart,  or  suffer- 
ing from  shell  shock,  re- 
quires sedative  treatment 
and  quietness.  His  bath 
should  not  be  in  the  same 
room  with  the  douche, 
where  there  is  continual 
traffic,  talking  and 
splashing. 

The  rest  room  should 
be  conveniently  placed  to 
both  douche  and  bath 
rooms.  It  should  be 
darkened  and  patients 
should  be  left  quiet  and 
undisturbed  for  an  hour 
or  more  after  treatment, 
well  wrapped  up  on  com- 
fortable couches. 

2.  For  local  treatments 
the  patient  usually  bares 
an  arm  or  leg  only,  and 
provision      for     dressing 


RECLAIMING    THE   MAIMED  9 

need  not  be  so  elaborate.  They  pass  in  a  continuous  stream 
through  the  treatment  rooms  from  bath  to  table  or  couch 
and  on  to  apparatus  and  the  gymnasium. 

The  floor  plan  should  be  arranged  to  keep  these  two 
streams  of  patients  apart.  For  massage,  electricity,  and 
corrective  exercise,  one  large  room  is  to  be  greatly  preferred 
to  several  small  ones.  There  is  no  great  objection  to  having 
arm  and  leg  baths  at  one  end  of  it.  The  head  masseuse  can 
supervise  her  work  much  better,  it  is  more  cheerful  for  the 
patients,  and  any  required  privacy  can  be  secured  by  screens. 
Plugs  should  be  inserted  at  short  intervals  around  the  wall 
to  connect  with  the  lamps,  photophores,  and  electrical 
appliances.  This  gives  flexibility  to  the  equipment,  and 
allows  the  setting  up  and  application  of  radiant  heat,  gal- 
vanic, or  sinusoidal  current  wherever  it  may  be  most  needed. 
Each  masseuse  should  have  her  own  couch  or  table,  and  the 
plinth  and  appliances  for  corrective  gymnastics  and  re- 
education should  be  placed  in  a  zone  down  the  center  of  the 
room. 

In  addition  to  the  case  history  which  follows  the  man 
wherever  he  goes,  a  card  should  be  issued  for  him  when  he 
starts  treatment.  This  card  should  contain  a  brief  case 
history,  diagnosis,  and  proposed  treatment.  The  masseuse 
in  charge  of  the  case  should  enter  on  it  the  measurements  of 
movement,  strength,  and  other  notes  of  progress.  It  should 
be  kept  by  her,  ready  for  inspection  by  the  medical  officer, 
and  when  the  case  is  finished,  it  should  be  used  as  a  store- 
house of  accurate  information  from  which  to  make  notes 
for  the  case  sheets.  The  card  should  then  be  filed  in  the 
records  of  the  Department. 

When  some  such  plan  is  not  used,  important  facts  are  sure 
to  be  lost  or  to  remain  unrecorded.  The  card  serves  as  a 
constant  reminder,  both  to  the  medical  officer  and  the 
masseuse,  and  in  dealing  with  large  numbers  of  patients, 
it  is  a  great  time  saver  as  well. 


CHAPTER  II 
MEDICAL   ELECTRICITY 

Galvanism,  Ionic  Medication 

The  subject  of  electricity  is  approached  by  many  medical 
men  in  an  attitude  of  apparent  contempt  but  of  very  real 
apprehension.  To  this  succeeds  an  increasing  confusion  of 
ideas  ending  in  a  final  collapse,  as  the  intricacies  of  the  various 
currents  or  ''modalities"  are  exposed  to  his  astonished  gaze, 
and  their  conflicting  claims  set  forth.  It  is  in  the  hope  of 
saving  the  reader  from  some  of  the  quagmires  through  which 
I  have  floundered  that  I  will  endeavor  to  bridge  some  of  the 
most  obvious  of  the  pitfalls  which  beset  the  unwary  trav- 
eler and  prevent  him  from  appreciating  the  real  value  of 
this  therapeutic  agent. 

Electricity  is  produced  by  chemical  action,  by  induction, 
and  by  friction,  all  these  forms  being  used  in  medical  treat- 
ment. 

Object.  —  The  object  of  electrical  treatment  is  (i)  to 
produce  heat  either  on  the  surface  or  in  the  tissues  and  so 
to  induce  hyperaemia  and  absorption  of  inflammatory  prod- 
ucts, (2)  to  cause  absorption  of  drugs,  (3)  to  stimulate 
nerves  and  so  produce  muscular  contraction,  (4)  to  cause 
muscular,  contraction  by  chemical  action  on  the  muscle 
tissue  itself,  and  (5)  to  soothe  and  alleviate  pain. 

Continuous  Current.  —  The  continuous  current  is 
produced  by  chemical  action.     If  we  take  an  earthen  vessel 

10 


RECLAIMING    THE   MAIMED 


11 


Copper  or  Carbon — ' 
Containing  vessel 

Electrol^ftlc  fluid 


\-Z\r\c  rod 


Fig.  7.  —  A  galvanic  cell. 


containing  dilute  sulphuric  acid  and  place  in  it  a  rod  of 
zinc  and  a  rod  of  copper,  there  is  a  transfer  of  electricity 
from  the  zinc  to  the  copper.  If  a  connecting  wire  is- placed 
between  the  copper  and  the  zinc,  electricity  will  flow  along 
it  back  to  the  zinc  in  order 
to  reestablish  the  equilib- 
rium, and  this  flow  of  elec- 
tricity will  cause  bubbles 
of  hydrogen  to  form  at  the 
copper  rod,  as  may  be 
readily  observed.  It  keeps 
paying  back  its  debt  to  the 
zinc.  The  part  of  the  plate 
to  which  the  wire  is  attached 
is  called  the  pole.  It  is 
quite  logical  then  that  the 
copper  should  be  called  the 
plus  pole  (anode)  and  the  zinc  the  negative  (cathode),  the 
part  which  is  immersed  being  called  the  plate  and  the  fluid 
the  electrolyte. 

There  are  many  influences  which  vary  the  strength  of 
the  current  induced  by  the  action  of  this  simple  cell  just 
described. 

If  the  hydrogen  bubbles  are  allowed  to  accumulate  on  the 
copper  plate,  the  layer  becomes  thick  and  acts  as  a  barrier 
so  that  the  current  is  weakened ;  and  finally  when  the  layer 
of  gas  becomes  thick  enough,  the  current  is  completely 
blocked.  This  is  called  polarization,  and  the  cell  may  be 
depolarized  by  wiping  the  bubbles  away. 

The  cell  just  described  has  been,  in  many  cases,  replaced 
by  the  dry  cell  in  which  the  electrolyte  is  a  solid  instead  of 
a  fluid,  but  the  chemical  action  is  in  every  case  substantially 
the  same. 

The  Variations  in  Current.  —  To  understand  the 
relationship  between  voltage,   resistance,   and  volume,   we 


12  RECLAIMING   THE   MAIMED 

may  take  a  simple  illustration.  Imagine  a  cistern  full  of 
water  placed  at  a  high  level.  If  it  has  no  outlet,  the  water 
remains  at  rest,  but  with  high  potentiality  for  power.  If 
a  pipe  be  arranged  leading  from  it  to  a  low  level  tank,  the 
water  will  flow  through  it  to  the  lower  tank  with  a  certain 
force.  This  may  be  compared  to  the  current  flowing  from 
the  positive  to  the  negative  pole.  The  strength  or  force 
of  the  stream  is  directly  dependent  upon  the  amount  of 
difference  in  the  two  water  levels.  The  pressure  of  this 
stream  is  comparable  to  the  voltage  of  the  electric  current. 
As  soon  as  the  high  level  cistern  is  emptied,  the  flow  of  water 
will  cease,  and  it  is  only  possible  to  have  a  continuous 
flow  by  pumping  the  upper  cistern  full.  Such  a  pump  may 
be  compared  to  an  electrolyte  which  keeps  continually  charg- 
ing the  positive  pole  and  taking  from  the  negative  pole. 
The  resistance,  measured  in  ohms,  in  the  wire  or  conductor 
and  in  the  tendency  to  polarization  as  already  described, 
resembles  the  slowing  of  water  by  the  friction  of  the  walls 
of  the  pipe.  The  volume  of  current  (measured  in  am- 
peres) will  vary,  according  to  the  resistance  and  the  caliber 
of  the  carrier.  The  greater  the  resistance,  the  smaller  will 
be  the  resultant  current,  just  as  a  narrow  and  tortuous  pipe 
will  allow  less  water  to  pass  through  it  than  a  large,  straight 
one.  To  get  a  greater  amount  of  water,  you  would  have  to 
reduce  the  resistance  by  using  a  bigger  pipe  or  straightening 
it,  or  else  raise  the  level  of  the  upper  cistern  to  increase  the 
pressure,  and  the  resistance  is  reduced  as  much  as  possible 
in  every  circuit  by  the  use  of  good  conductors.  The  follow- 
ing electrical  units  have  been  adopted. 

A  volt  is  the  amount  of  electromotive  force  generated  by 
a  Daniell's  cell,  which  is  standardized.  While  this  is  only 
approximately  correct,  other  cells  are  always  measured  with 
this  for  comparison. 

Currents  for  lighting  purposes  usually  consist  of  either 
no  volts  or  220  volts.    For  medical  purposes,  the  voltage 


RECLAIMING    THE   MAIMED  13 

is  usually  very  small  in  comparison,  except  in  static  and  high 
frequency  machines,  where  it  rises  to  looo  or  more  with 
very  small  volume. 

The  unit  of  resistance  (the  ohm)  is  that  offered  by  a 
copper  wire  looo  feet  long,  and  ^  inch  in  cross  section. 
With  this,  other  resistances  can  be  measured.  The  resist- 
ance of  the  human  body  with  a  wet  skin  has  been  quoted 
as  between  looo  and  300  units,  or  ohms. 

A  unit  of  current  is  called  an  ampere.  It  is  the  quantity 
of  electricity  which  an  electromotive  force  of  one  volt  will 
cause  to  flow  through  a  resistance  of  one  ohm  in  one  second. 

The  ampere  is  too  large  a  unit  for  medical  purposes  and 
a  thousandth  part  is  employed  as  the  most  convenient  unit. 
It  is  called  a  milliampere. 

It  will  thus  be  evident  that  with  resistance  remaining 
constant,  doubling  the  voltage  doubles  the  current,  or  "The 
current  varies  directly  as  the  voltage."  If  the  voltage  re- 
mains constant,  then  doubling  the  resistance  halves  the  cur- 
rent; or  halving  the  resistance  doubles  the  current,  or  "The 
current  varies  inversely  as  the  resistance." 

The  current  can  be  varied  in  any  of  these  respects  by 
combining  cells  in  series  or  in  parallels.     The  joining  of  two 


Fig.  8.  —  Cells  arranged  in  series. 

cells  negative  to  positive  forms  a  battery.  If  they  are  joined 
in  a  series  by  means  of  connecting  wires,  it  is  as  if  you 
added  a  number  of  pumps  to  a  pipe  containing  water.  The 
result  will  be  an  enormous  increase  in  the  force  in  which  the 
water  is  driven  along,  or,  in  electricity,  an  increased  voltage. 


14 


RECLAIMING   THE  MAIMED 


but  the  volume  will  not  be  correspondingly  increased  be- 
cause much  of  the  effort  will  be  spent  in  overcoming  the  in- 
creased resistance.  Currents  with  high  voltage  and  small 
volume  are  used  in  medical  practice  for  diathermy,  where 
the  resistance  of  the  tissues  is  shown  by  the  production  of 
heat.  If,  however,  cells  are  joined  in  parallel,  it  is  as  if  we 
had  a  common  reservoir  which  we  wished  to  fill  with  water 
and  a  number  of  pumps,  not  joined  one  after  the  other,  but 
each  acting  independently  and  pouring  its  own  stream  into 
the  reservoir.  The  force  of  the  flow  will  be  small  (that  of 
one  pump),  but  the  volume  will  be  great  in  a  given  time. 


Fig.  9.  —  Cells  arranged  in  parallel. 


In  other  words,  the  parallel  grouping  gives  a  voltage  equal 
to  one  cell  only,  but  the  internal  resistance  being  reduced, 
the  current  or  ampereage  is  increased,  and  we  have  a  large 
current  flowing  at  a  low  voltage.  This  is  the  current  used 
for  the  cautery  and  diagnostic  lamps. 

A  galvanic  battery  consists  of  a  suitable  box  containing 
cells  and  a  switchboard  to  which  they  are  connected  by 
conducting  cords  of  copper  wire.  On  this  switchboard  are 
found  the  terminals  to  which  the  connecting  cords  are 
attached,  leading  to  the  electrode  by  which  the  current  is 
applied  to  the  patient,  a  switch  to  turn  the  current  off  and 
on,  a  milliamperemeter  to  measure  it,  a  metronome  or 
rheotome  to  interrupt  it,  and  a  rheostat  or  cell  collector  to 
increase  or  decrease  the  amount  and  strength  of  the  current. 


RECLAIMING    THE   MAIMED 


15 


The  binding  screws  or  terminals  are  marked  plus  for  the 
positive  pole  or  anode  and  minus  for  the  negative  pole  or 
cathode. 

6 


O 


O. 


o 


O- 


o. 


v8 


O 


O 


O- 


40)  )ii 


Pa  t  lent 


0+ 


Fig.  io.  —  Cell  collector. 


Effect  of  Galvanic  Current  upon  the  Muscles.  — 
A  constant  current  produces  no  contraction  when  flowing 
with  uniform  strength  through  the  body;  but  if  it  is  sud- 
denly cut  off  or  broken,  a  muscular  contraction  is  produced. 
If  it  is  suddenly  switched  on  (or  made),  a  muscular  contrac- 
tion is  also  produced.  These  contractions  are  not  equal 
either  at  the  break  or  make  of  the  current  or  at  both  poles, 
for  the  contraction  at  the  cathode  when  a  current  is  turned  on 
is  much  the  most  active.  Various  devices  are  used  to  in- 
terrupt the  galvanic  current  and  produce  these  contractions. 


16 


RECLAIMING    THE   MAIMED 


The  chief  devices  are  the  reversing  switch  and  the  metro- 
nome. The  simplest  form  of  metronome  is  a  wire  rhyth- 
mically introduced  and 
withdrawn  in  a  cup  of 
water ;  the  strength 
of  the  current  varies 
with  the  depth  of  im- 
mersion as  it  rises  and 
sinks,  so  that  the 
patient  will  receive  a 
current  of  constantly 
varying  intensity,  ris- 
ing and  falling  in 
waves.  It  is  also 
possible  to  reverse  it 
by  the  use  of  the  pole 
changer  and  so  to  have 
the  direction  of  the 
current  change  at  each  insertion.  "Sinusoidal"  is  the  term 
applied  to  a  current  which  starts  at  zero,  comes  up  to  its 

.mnnnnmmmmnmmn 

Fig.  12.  —  Current  varied  by  the  metronome. 

full  strength  on  the  positive  side,  of  the  line,  and  goes  back 
to  zero,  forming  what  is  called  a  true  sine  curve.     It  then 


Fig.  II.  —  Reversing  switch. 


Fig.  13.  —  Sinusoidal  current  from  the  metronome  and  pole  changer. 

repeats  this  on  the  negative  side,  so  that  there  is  an  alternat- 
ing current  positive  and  negative,  rhythmical  in  character. 


RECLAIMING   THE  MAIMED 


17 


This  is  found  to  be  very  much  less  irritating  and  painful 
than  if  the  current  were  opened  and  closed  abruptly,  and 
in  consequence  this  current  is  the  most  popular  for  general 
use  in  muscular  stimulation. 

Galvanometer.  —  This  is  an  instrument  for  measuring 
the  amount  of  a  constant  current.  It  is  graduated  in  milli- 
amperes  for  medical  instruments, 
and  the  deflection  of  the  needle 
records  the  strength  of  the  current, 
the  amount  being  recorded  on  the 
scale. 

Very  different  effects  are  pro- 
duced on  the  tissues  by  the  electric 
current  at  the  anode  and  the 
cathode.  The  direction  of  the 
current  may  be  determined  easily 
by  litmus  paper.  A  strip  is  laid 
upon  a  wet  surface  and  the  current 
is    led    through    it.     Blue    litmus 

paper  turns  red  at  the  anode,  where  acids  are  produced,  and 
red  litmus  paper  turns  blue  around  the  cathode,  where 
alkalis  are  produced.  There  are  other  tests,  but  this  is 
perhaps  the  simplest. 

Physiological  Effects  ;  Electrotonus.  —  The  irritabil- 
ity of  the  nerve  and  muscle  through  which  a  constant  current 
is  passing  is  altered  as  follows :  In  the  region  of  the  anode, 
irritability  is  decreased  and  muscular  contraction  is  less 
readily  obtained,  the  circulation  is  lowered,  sensation  is 
decreased,  and  pain  is  deadened.  In  the  region  of  the 
cathode,  muscular  contraction  is  more  readily  obtained, 
sensation  is  increased  and  there  is  hyperaemia  and  redden- 
ing of  the  part. 

Chemical.  —  The  human  body  contains  a  large  amount 
of  sodium  chloride  in  solution.     The  constant  current  splits 
salts  into  their  constituents,  the  metallic  portion  being  at- 
c 


Fig.  14.  —  Milliamperemeter. 


18  RECLAIMING   THE  MAIMED 

tracted  to  the  cathode,  and  the  acid  portion  to  the  anode. 
This  change  in  the  tissues  can  be  made  use  of  medically,  for 
fatigue  products  in  the  muscles,  such  as  carbonic  acid  and 
sarcolactic  acid,  which  result  from  excessive  muscular  ac- 
tivity, are  dispersed  by  the  cathode.  This  constitutes  what 
is  known  as  the  "refreshing"  action  of  the  current,  but 
since  the  anode  attracts  acids  and  repels  metals,  we  can  also 
drive  solutions  of  certain  metals  into  the  tissues  by  this 
action  of  the  anode. 

This  introduction  of  the  salts  of  such  metals  as  lithium 
and  copper  by  the  anode  and  of  iodine  and  sodium  by  the 
cathode  is  known  as  ionic  medication. 

Application  of  the  Galvanic  Battery.  —  Certain 
precautions  must  be  observed  before  using  the  galvanic 
battery. 

The  skin  of  the  patient  should  be  carefully  examined  for 
abrasions.  Wherever  the  skin  is  broken,  the  resistance  is 
lowered,  and  the  current  will  concentrate  at  such  areas, 
causing  a  more  or  less  serious  burn.  If  possible,  the  area 
chosen  for  the  application  should  be  where  the  skin  is  normal. 
If  this  is  impossible,  the  abrasions  must  be  protected  by  cover- 
ing them  with  collodion  or  adhesive  plaster.  The  part 
should  be  thoroughly  moistened  to  improve  conduction. 
A  dry  or  greasy  skin  increases  the  resistance.  Electrodes 
to  which  the  connecting  wires  from  the  battery  are  attached 
will  vary  with  the  region  to  be  treated.  They  come  in  many 
sizes  and  shapes,  but  can 'be  improvised  out  of  copper  wire 
mesh  to  which  are  soldered  the  binding  screws.  They  are 
covered  with  felt,  cotton  wool,  or  lint,  the  essentials  being 
that  they  should  be  clean,  soft,  smooth,  and  absorbent,  and 
at  least  one  fourth  of  an  inch  thick.  Great  care  should  be 
taken  to  have  them  applied  to  the  body  uniformly  flat  and 
free  from  creases.  Burns  occur  at  a  crease  because  here  the 
pressure  is  greater  than  elsewhere.  The  pad  should  also  ex- 
tend well  beyond  the  metal  edge  of  the  electrode  on  every 


RECLAIMING   THE  MAIMED 


19 


side.  Electrodes  and  pads  may  be  kept  in  firm  position 
for  treatment  by  the  pressure  of  a  well-applied  bandage, 
by  sandbags,  or  other  weights. 

The  two  electrodes  should  not  be  placed  close  enough  to 
touch  each  other,  as  the  current  would  then  become  short- 
circuited  instead  of  penetrating  the  tissues. 

When  both  electrodes  have  been  correctly  applied,  the 
current  is  turned  on  very  slowly  and  gradually,  cell  after 


Fig.  15.  —  Continuous  current  applied  to  the  sciatic  nerve  by  elec- 
trodes of  copper  mesh  covered  by  felt,  and  held  in  place  by  sand- 
bags across  the  thigh. 


cell  being  brought  into  the  circuit.  The  patient  soon  becomes 
conscious  of  a  sharp  pricking  sensation  and  a  feeling  of  heat. 
As  the  unpleasantness  of  this  diminishes,  the  current  can  be 
increased.  If  the  patient  complains  of  much  discomfort 
or  burning,  the  current  should  be  slowly  decreased  and  the 
electrodes  remoistened  and  adjusted. 


20  RECLAIMING   THE  MAIMED 

The  region  of  the  cathode  is  the  danger  point.  Watch 
it.  Here  burns  are  most  hkely  to  occur.  Where  anaesthetic 
areas  are  treated,  keep  a  double  lookout  for  possible  burns, 
because  the  patient  cannot  help  you ;  however  severely  he 
may  be  burnt,  he  will  not  have  any  complaints  at  the  time. 
Burning  may  be  caused  by  too  small  a  pad,  and  a  good  rule 
is  to  allow  one  square  inch  of  electrode  for  every  milliampere 
of  current  used. 

At  the  termination  of  treatment,  the  current  should  be 
turned  off  slowly  and  carefully.  If  you  turn  it  off  suddenly 
you  will  hear  from  the  patient,  and  what  you  hear  will  not 
be  complimentary.  The  electrodes  should  not  be  removed 
until  the  current  is  completely  turned  off.  The  skin  must 
at  once  be  carefully  dried  and  examined  for  undue  redness, 
blisters,  or  burns. 

After  using  a  battery,  all  switches  should  be  turned  off, 
the  cords  and  electrodes  dried,  and  metal  parts  polished  and 
freed  from  all  verdigris,  and  the  pads  rinsed  out  and  kept 
in  an  antiseptic  solution  or  dried. 

Methods.  —  When  both  anode  and  cathode  are  placed 
upon  the  affected  part,  and  are  of  use  in  the  treatment, 
the  method  is  called  bipolar  galvanism.  If  only  one  is  wanted 
and  the  other  would  be  detrimental,  the  pole  placed  upon  the 
affected  part  is  called  the  active  electrode,  while  the  other 
pole  or  indifferent  electrode  is  placed  upon  some  remote 
part  of  the  body  and  used  merely  to  complete  the  circuit. 
This  is  called  unipolar  galvanism. 

The  method  of  application  already  described  is  stabile 
or  stationary  because  both  electrodes  are  fixed  upon  the 
patient  and  kept  at  rest  throughout  the  treatment. 

When  the  active  electrode,  usually  in  the  form  of  a  roller 
disk  or  sponge,  is  moved  up  and  down  or  on  and  off  the  part 
treated,  it  is  called  labile  or  movable  ;  and  the  action  becomes 
stronger  or  weaker  with  its  approach  to,  or  recession  from, 
the  part  under  treatment. 


RECLAIMING    THE   MAIMED  21 

Effect  of  Constant  Current.  —  The  constant  current 
applied  to  the  whole  body  by  means  of  a  general  bath  has  a 
profound  effect  upon  metabolism.  For  painful  local  condi- 
tions, the  anode  is  used  for  neuritis  in  its  various  forms,  neu- 
ralgia, and  inflammation.  The  cathode  is  used  to  stimulate 
the  circulation  in  such  conditions  as  frost-bite  or  trench  foot, 
old  scars,  Volkman's  ischaemic  contraction,  and  other  con- 
ditions requiring  active  hyperaemia.  This  may  be  applied 
in  a  local  bath ;  or  where  this  is  unavailable,  the  labile  method 
may  be  substituted,  the  body  being  treated  area  by  area. 

Ionic  Medication.  —  The  salicylates  of  soda  are  recog- 
nized as  being  of  use  for  rheumatic  affections,  lithium  for 
gout,  and  copper  and  zinc  as  antiseptics,  while  chlorine 
seems  to  possess  the  additional  virtue  of  softening  recently 
formed  inflammatory  tissue.  Instead  of  taking  these  drugs 
by  the  mouth  they  can  be  driven  into  the  body  by  means 
of  the  galvanic  current. 

These  salts  when  dissolved  in  water  will  split  up  into 
atoms  called  "ions"  or  "wanderers"  or  travelers,  and  the 
process  is  called  ionization.  In  this  way  salts  of  iodine, 
sodium,  chlorine,  and  potassium  are  driven  in  by  the  cathode, 
which  repels  alkalis,  while  the  salts  of  lithium,  zinc,  copper, 
and  magnesium  are  driven  in  by  the  anode,  which  repels 
metals.  A  one  per  cent  or  two  per  cent  solution  of  the 
required  drug  is  made,  and  the  padding  which  covers  the 
active  electrode  is  dipped  into  it.  The  amount  that  will  be 
driven  in  depends  on  the  strength  of  current  and  the  length 
of  time  it  runs,  the  usual  treatment  lasting  about  twenty 
minutes.  Heat  your  solution.  It  gives  comfort  to  the  patient, 
and  it  forms  a  better  conductor  for  the  current.  These 
drugs  are  put  up  in  the  form  of  soloids  especially  prepared 
for  this  purpose,  but  it  is  quite  as  convenient  to  have  them 
in  stock  solutions  of  about  twenty  per  cent,  which  you  can 
dilute  to  the  required  one  per  cent,  as  required.  The  drugs 
you  will  need  are :  salicylate  of  sodium  for  chronic  arthritis, 


22 


RECLAIMING    THE  MAIMED 


fibrositis,  myositis,  and  for  certain  forms  of  bursitis,  rheu- 
matism, neuritis  in  its  various  forms,  especially  lumbago 
and  sciatica,  and  for  the  chronic  pain  so  often  left  after  in- 
juries to  joints  and  limbs;  iodine  in  the  form  of  potassium 
iodide,  as  an  antiseptic ;    chlorine  in  the  form  of   sodium 


Fig.  i6.  —  Application  of  sodium  chloride  solution  by  the  cathode 
in  an  arm  bath  —  for  painful  scars. 

chloride  or  common  salt  for  the  treatment  of  irritable  con- 
tracting scars  —  all  these  introduced  by  the  cathode.  Zinc, 
in  the  form  of  sulphate  or  chloride,  and  copper  sulphate 
are  valuable  antiseptics,  for  suppurating  sinuses,  chronic 
ulcers,  and  other  slow  infective  conditions.  They  are  in- 
troduced by  the  anode  through  electrodes  of  zinc  and  copper 
respectively. 


CHAPTER   III 
MEDICAL   ELECTRICITY 

Faradism 

Induction.  —  The  second  form  of  electricity  used  in 
medicine  is  produced  by  induction. 

If  you  introduce  a  magnet  into  a  coil  of  wire  forming  a 
closed  circuit,  an  electric  current  is  produced  running  in  one 
direction.  Withdraw  it,  and  its  direction  is  reversed.  Keep 
it  still,  and  no  current  will  flow.  If  the  coil  is  made  to  move 
in  relation  to  a  stationary  magnet,  alternating  currents  are 
also  produced.  This  briefly  is  the  principle  upon  which  the 
dynamo  works.  Wind  a  coil  of  wire  around  a  bar  of  soft 
iron  and  pass  a  current  along  the  wire ;  the  iron  bar  becomes 
magnetized.  So  long  as  the  current  runs,  it  is  an  electro- 
magnet. If  a  closed  coil  of  wire  carrying  a  current  be  brought 
into  the  neighborhood  of  another  coil,  electric  currents  are 
produced  in  this  second  coil  whenever  the  current  is  made 
or  broken.  This  induced  current  in  the  secondary  coil  passes 
in  the  same  direction  as  the  inducing  current  when  the  cir- 
cuit is  broken,  and  in  the  opposite  direction  when  the  current 
is  made.  Thus  we  obtain  the  alternating  current.  Its  voltage 
can  be  made  high  by  having  a  larger  number  of  turns 
of  wire  in  the  secondary  coil,  so  that  a  low-voltage  inducing 
current  can  produce  an  alternating  current  of  high  voltage  in 
the  secondary  coil.  Keep  these  facts  in  mind  and  the  mech- 
anism of  the  faradic  battery  will  be  easily  understood.  Its 
essential  parts  are :   (i)  a  source  from  which  a  continuous 

23 


24 


RECLAIMING   THE  MAIMED 


current  can  be  obtained ;  (2)  a  stationary  coil  of  wire  wound 
on  a  wooden  bobbin,  "the  primary  coil" ;  (3)  a  device  in  the 
circuit  of  the  primary  coil  for  making  and  breaking  this 
current,  "vibrating  armature"  ;  (4)  a  second  coil  of  wire  un- 
connected with  the  first,  also  mounted  on  a  hollow  wooden 
bobbin,  "the  secondary  coil,"  in  which  induced  alternating 


Fig.  17.  —  Diagram  of  faradic  coil. 

A.  Core  and  primary  coil.    B.  Condenser.    D.  Secondary  coil  and  terminals  -\ . 

c,  b,  d.  Armature. 

currents  are  produced ;  (5)  an  iron  core  in  the  center  of  the 
wooden  bobbin  which  becomes  magnetized  by  the  currents 
passing  in  the  coils,  (6)  binding  screws  to  which  electrodes 
can  be  attached  to  convey  the  current  from  the  primary  or 
the  secondary  coil  to  the  patient. 

When  a  current  source  is  connected  with  the  binding 
screws,  from  an  outside,  a  circuit  is  completed  as  in  the  fol- 
lowing diagram : 


RECLAIMING   THE  MAIMED 


25 


(i)  Through  binding  screw,  A. 

(2)  Up  the  metal  support,  B. 

(3)  Along  the  limb  of  the  hammer  to  the  contact  screw,  C. 

(4)  From  the  contact  screw  to  the  primary  coil,  D. 

(5)  From  primary  coil 
to  electromagnet,  E. 

(6)  From  electromag- 
net to  binding  screw,  F. 

(7)  Thence  back  to 
cell. 

At  the  moment  that 
the  current  passes  from 
the  cell  through  the  cir- 
cuit, the  iron  rod  E  is 
converted  into  an  elec- 


FiG.  19.  —  Current  closed. 


Current  open. 

tromagnet  strong  enough 
to  attract  the  head  of  the 
hammer,  thus  drawing 
down  the  limb  of  the 
hammer  out  of  touch 
with  the  contact  screw. 
When  the  hammer  leaves 
the  contact  screw,  the 
following  sequence  of 
events  takes  place: 


26  RECLAIMING   THE  MAIMED 

(i)  The  circuit  is  broken  at  the  contact  screw. 

(2)  The  current  ceases  to  flow. 

(3)  The  iron  rod  ceases  to  be  a  magnet. 

(4)  The  hammer  is  released,  and  is  caused  to  fly  back  to 
the  contact  screw  by  the  tension  of  its  wire  spring. 

(5)  The  circuit  is  remade  at  the  contact  screw. 

(6)  The  current  again  flows  through  the  circuit. 

(7)  The  iron  rod  is  remagnetized,  attracting  the  hammer  to 
it  and  again  breaking  the  circuit. 

(8)  This  sequence  of  events  occurs  again  and  again  with 
great  rapidity :  thus  the  constant  current  from  the  cell  is 
automatically  converted  into  the  rapidly  interrupted  current 
of  the  primary  winding. 

The  rate  at  which  these  interruptions  can  be  produced  can 
be  varied  by  adjustments  of  the  interrupter.  The  arrange- 
ment of  the  two  coils  and  of  the  central  core  varies  with  dif- 
ferent instruments,  but  the  principle  is  the  same.  The  pri- 
mary coil  gives  an  interrupted  current  flow  in  one  direction 
which  resembles  the  interrupted  galvanic  current  except 
that  it  is  jerky  and  uneven,  the  make  and  break  being  of  dif- 
ferent strengths,  and  it  is  painful  to  the  patient.  The  current 
in  the  secondary  coil  alternates  rapidly  but  the  alternatives 
are  uneven.  It  is  always  to  be  remembered  that  the  currents 
in  the  secondary  coil  are  induced  and  have  no  direct  continuity 
with  those  of  the  primary. 

One  of  the  most  useful  forms  of  faradic  battery  has  the 
same  number  of  layers  of  wire  in  the  secondary,  which  is  the 
current  used,  as  those  in  the  primary,  the  secondary  current 
being  no  stronger  than  the  primary  in  consequence,  with  an 
interrupter  arranged  to  give  perfect  regularity  of  rhythm, 
and  a  condenser  to  steady  the  current.  In  it  a  thick  core  of 
soft  iron  is  made  to  slide  easily  in  the  primary  bobbin.  The 
sliding  of  the  iron  core  in  and  out  regulates  the  current  by 
decreasing  the  amount  of  the  current  which  is  in  use  as  the 
core  is  withdrawn  and  increasing  it  as  it  is  shoved  in.     This 


RECLAIMING    THE   MAIMED 


27 


produces  a  painless  muscular  contraction  which  is  capable  of 
perfect  control,  the  operator  being  enabled  to  produce  any- 
thing from  a  faint  tremor  to  full  contraction  of  the  muscle. 

Effects.  —  The  effect  of  the  faradic  current  upon  mus- 
cular tissue  is  very  much  like  that  of  the  normal  nerve  im- 
pulse to  the  healthy  muscle.  The  current  is  readily  conducted 
along  the  nerve  and  enters  the  muscle  through  it.  It  is 
rapidly  distributed  to  every  part  of  the  muscle  and  throws 
it  into  a  series  of  contractions  synchronous  with  the  make 


Fig.  20.  —  Curves  of  primary  (£),  and  secondary  (5)  faradic  current. 


and  break  of  the  current.  If  the  interruptions  are  rapid 
enough  and  the  current  strong  enough,  the  muscle  fibers  are 
thrown  into  tetanus,  which  causes  rapid  exhaustion.  At 
each  normal  contraction  of  a  muscle  the  blood  is  squeezed  out 
and  new  blood  flows  in  during  relaxation,  but  in  tetanus  the 
muscle  strangles  itself.  The  value  of  faradism  from  a  med- 
ical standpoint  lies  in  its  power  to  act  as  a  substitute  to 
normal  nerve  impulses  when  they  are  not  fully  conveyed  to 
the  muscle. 

When  nerves,  through  disease  and  degeneration,  have  lost 
all  power  of  conducting  their  normal  impulses,  the  muscles 
remain  passive  under  this  form  of  electric  stimulation ;  but  if 
we  turn  on  the  galvanic  current  to  the  same  muscle,  it  will 
sluggishly  respond  to  the  chemical  stimulation  of  its  sub- 
stance.   This  difference  in  the  action  of  the  two  currents  on 


28  RECLAIMING   THE  MAIMED 

the  same  muscle  enables  us  to  secure  the  "reaction  of  de- 
generation." 

Use  of  the  Faradic  Battery.  —  Place  the  indifferent 
electrode,  a  metal  plate  four  or  five  inches  square  covered 
with  lint,  over  the  nerve  trunk  or  plexus  and  the  active 
electrode  over  the  motor  point,  after  wetting  them  both  in 
soapy  water  to  remove  grease.  The  active  electrode  should 
be  a  metal  disk  about  two  inches  in  diameter  covered  with 
lint.  The  electrode  is  grasped,  together  with  the  muscle, 
between  the  thumb  and  forefinger  of  the  left  hand,  and  with 
the  other  hand  gradually  insert  the  core  into  the  coil.  The 
amount  of  contraction  is  estimated  by  the  feel  of  the  muscle 
under  the  left  hand.  The  core  is  inserted  and  withdrawn 
rhythmically  at  about  one-second  intervals,  or  the  mechanical 
metronome  is  used.  Fatigue,  felt  by  weak,  irregular  con- 
tractions, is  a  signal  to  stop.  The  motor  points  of  all  the 
muscles  can  be  found  by  consulting  any  good  chart.  Great 
care  must  be  taken  not  to  produce  exhaustion,  as  muscles 
recover  slowly,  and  may  be  badly  damaged  by  overstimu- 
lation.^ 

This  surging  faradism  is  also  used  in  applying  strong  cur- 
rents over  large  areas,  the  current  being  slowly  and  rhyth- 
mically increased  and  decreased  by  the  metronome  or 
rheostat.  In  this  way  a  good  substitute  for  exercise  can  be 
obtained.  Bergonie  has  used  it  for  exercising  the  abdominal 
muscles  in  obesity,  and  Kellogg  for  cases  where  the  heart 
will  not  permit  more  active  exercise. 

The  general  effect  of  faradism  is  to  stimulate  muscle  ac- 
tivity, and  to  improve  the  local  circulation  by  which  the 
general  nutrition  of  the  patient  is  benefited.  This  stimu- 
lation is  employed  in  many  conditions  from  which  wounded 
soldiers  suffer.  In  functional  neuroses,  the  thyroid  glands, 
which  are  so  frequently  enlarged,  may  be  reached  by  its 
application  to  the  sides  of  the  neck.     Many  cases  of  aphonia 

^  Treatment  of  Joint  and  Muscle  Injuries,  by  W.Rowley  Bristow. 


RECLAIMING   THE  MAIMED  29 

are  cured  by  its  careful  use  over  the  laryngeal  muscles,  throw- 
ing them  into  spasm  violent  enough  to  make  the  patient  cry 
out.  In  the  treatment  of  weakened  muscles  the  current 
should  be  strong  enough  to  produce  a  brisk  contraction,  but 
not  strong  enough  to  cause  pain,  and  the  dangers  of  over- 
fatigue must  always  be  kept  in  mind. 

Combinations  of  Electric  Currents.  — The  galvanic 
and  faradic  may  be  combined.     If  a  part  of  a  muscle  or 


Fig.  21.  —  The  Mcintosh  polysine  generator. 

group  v/ere  responsive  to  galvanic  stimulation  only,  it  would 
be  neglected  if  the  faradic  stimulation  only  were  used. 

They  are  combined  on  most  switchboards  and  on  all  of  the 
combination  machines  known  as  pantostats,  multostats,  com- 
postats,  or  universal  machines.  These  machines  in  every 
case  consist  of  a  small  motor  which  is  used  to  operate  a 
dynamo  which  generates  a  current.  This  current  has  no 
direct  connection  with  the  source  of  supply  to  the  dynamo. 
It  is  of  low  voltage  and  can  be  used  for  treatments  with  per- 


30 


RECLAIMING   THE  MAIMED 


Fig.  22.  —  Medical  switchboard. 


RECLAIMING    THE   MAIMED 


31 


feet  safety.  If  the  current  from  the  main  were  used,  it 
would  be  too  high  in  voltage  and  would  also  be  danger- 
ous if  suddenly  interrupted  while  the  galvanic  current  was 
in  operation,  as  it  will  be  remembered  that  a  twitch  is  pro- 
duced every  time  the  current  is  made  or  broken.  This 
low-voltage  current  is  led  off  to  various  terminals  labeled 
galvanic,  faradic,  and  sinusoidal,  with  their  combinations. 

Switchboard.  —  The    medical    switchboard    is    supplied 
from  a  main  current  or  accumulator,  and  is  then  distributed 


Fig.  23.  —  Diagram  of  rheostat. 

to  the  terminals  through  certain  safety  devices  which  pre- 
vent sudden  variations  in  strength.  These  consist  of  the 
fuse,  or  blow-out,  to  prevent  the  current  from  becoming  too 
strong,  and  the  rheostat  for  regulating  its  strength.  There 
are  also  the  reversing  switch  for  changing  direction  and  the 
galvanometer  for  measurement. 

Both  forms  of  electricity  are  in  constant  use  for  injuries  in 
which  the  nerves  are  completely  or  partly  destroyed,  and  the 
stiff,  contracted,  or  weak  hand  may  make  its  first  movement 
towards  recovery  through  their  use.     For  paralyses,  tremors, 


32  RECLAIMING   THE   MAIMED 

areas  of  anaesthesia,  and  disturbances  of  the  special  senses,  the 
more  stimulating  forms  would  be  effective.  The  disorderly 
heart  can  be  helped  back  to  reason  by  f aradism  and  the  sinus- 
oidal current,  and  ionic  medication  has  proved  its  value  for 
rheumatism  in  its  many  forms  and  in  the  after-effects  of 
wounds  resulting  in  sinuses  or  in  the  formation  of  scar  tissue 
and  contractures,  as  has  already  been  insisted  upon. 

Condenser  Impulses.  —  The  condenser  may  be  considered 
as  a  means  of  storing  a  definite  quantity  of  electricity. 
It  consists  of  two  insulated  conductors  each  presenting  a 

large  surface  to  the 
other  with  a  small  dis- 
tance between  them. 
When  one  conductor  is 
connected  to  earth,  a 
small  electromotive  force 
is  able  to  charge  the 
other  with  a  much  larger 
quantity  of  electricity 
than  if  it  stood  alone. 

Fig.  24.  —  OscilLtory  discharge  of  Leyden  jar.    The    Leyden    jar    is    an 

example.  (See  also  Fig. 
17,  B.)  The  discharge  of  a  condenser  through  a  coil  takes 
place  by  a  series  of  oscillations  like  that  of  a  flexible  bent 
rod  when  released. 

High  Frequency. — An  induced  current  having  a  frequency 
of  millions  to  the  second,  at  a  high  voltage  and  low  amperage, 
can  thus  be  obtained  by  introducing  into  the  circuit  a  Leyden 
jar,  a  spark  gap,  and  a  solenoid  (wire  spiral).  This  form 
of  current  is  applied  direct  to  the  patient  through  vacuum 
electrodes,  or  metal  plates  grasped  by  him  or  placed  against 
his  skin.  The  rapidity  of  the  oscillations  is  such  that  a  large 
volume  of  the  current  (800  milliamperes)  produces  but  slight 
physiological  or  chemical  effect,  and  muscular  twitches  or 
stinging  sensations  are  not  perceived  from  this  current,  how- 


RECLAIMING    THE   MAIMED 


33 


ever  strong,  which  changes  its  direction  at  a  rate  of  a  million 
to  the  second.  Its  strength  is  controlled  by  a  rheostat.  It  is 
even  possible  to  light  a  high-powered  incandescent  lamp 
through  the  body,  without  any 
shock  or  other  feeling,  except  one 
of  heat. 

Diathermy.  —  The  quality  for 
v/hich  it  is  most  used  in  medical 
treatment  is  the  production  of 
heat,  caused  by  the  resistance  the 
tissues  offer  to  its  passage.  The 
patient    grasping    the    electrode 


STE.PUP 

T(<AN5. 


Coll 


Cond- 


Fig.  25.  —  High  frequency  apparatus. 


Fig.  26.  —  Composite  high  fre- 
quency apparatus. 


feels  an  immediate  sensation  of  warmth,  and  it  can  be  demon- 
strated that  its  penetration  is  great,  and  affects  the  most 
deep-lying  tissues.      It  is  of   value  for  the  production  of 


34 


RECLAIMING   THE  MAIMED 


hyperaemia,  and  makes  an  excellent  preparation  for  massage, 
by  flushing  a  joint  or  area  of  scar  tissue  with  blood  just  as 
is  done  by  a  hot  bath. 


Fig.  27. — High  frequency  (i)  and  diathermy  (2)  oscillatory  discharges 
compared.     Lewis  Jones. 

Static  Electricity.  —  The  third  and  oldest  method  of 
producing  the  electric  current  is  by  friction,  and  in  the  earlier 
machines  this  was  done  by  revolving  a  glass  plate  between 
stationary  brushes.  The  brushes  were  charged  positively 
and  negatively  so  long  as  the  plate  revolved,  producing  a 
continuous  current  of  high  voltage  and  small  volume.  The 
next  step  was  to  start  the  machine  by  friction  and  continue 
its  action  by  ''influence"  or  induction.  In  the  Holtz  ma- 
chine, one  plate  of  glass  revolves  in  close  proximity  to  another 
slightly  larger  one.  The  machine  first  is  charged  from  an 
outside  source  before  starting,  but  the  current  continues, 
once  it  is  started.     The  Wimshurst  machine  is  self-starting. 


RECLAIMING    THE   MAIMED 


35 


It  consists  of  from  two  to  twelve  circular  glass  disks  mounted 
in  pairs  and  made  to  rotate  in  opposite  directions  at  a  dis- 
tance apart  of  not  more  than  a  fraction  of  an  inch.  It  is 
really  a  friction  machine  as  well  as  one  using  induction  or 
''influence."  Owing  to  the  high  tension  of  the  current,  in- 
sulation is  important,  and  the  patient  is  usually  placed  upon 
a  platform  with  glass  legs.  The  electrodes  used  are  a 
point,  a  ball,  a  roller,  and  a  brush.  As  it  gives  a  con- 
tinuous current,  it  has  polarity,  and  this  must  be  deter- 
mined  by   the   character   of   the   spark.     The    treatments 


/I  J 

Nz 

^ 

n  1-  -1  \-'-\ 

-^\ 

!-;-!  1- -1  r^ 

^  1+  +1  K  +1  r^ 

•6-            7               i 

i             ^            ^             ::             J 

'                 J              6< 

B  ?• 

— »■  < 

Vv 

i            r| 

p 

J 

+- 

^ 

J' 

:0  e= 

7       r 

Fig.  28.  —  Diagram  of  static  machine. 
J ,  J ,  Leyden  jars.    C,  C,  Collecting  brushes.    A,  B,  Glass  plates.     T,  T,  Terminals. 

are  simple  charging,  which  increases  blood  pressure  and 
pulse  rate,  but  acts  as  a  sedative  in  sleeplessness,  when 
the  anode  is  used ;  the  Morton  wave  current,  a  static  wave, 
in  which  the  patient  is  alternately  charged  and  discharged, 
producing  contractions,  a  tonic  treatment ;  the  brush  dis- 
charge, or  breeze,  which  gives  a  cool  and  agreeable  sensa- 
tion like  a  douche  of  hot  sand,  leaving  a  warm  glow 
after-effect  —  it  is  useful  in  soothing  the  pain  of  neu- 
ralgia, neuritis,  and  nervous  irritability  of  "shell  shock"; 
single  sparks,  given  by  the  ball  —  the  effect  is  like  a  blow, 
and  is  followed  by  a  reflex  muscular  contraction,  stimulat- 


36 


RECLAIMING   THE  MAIMED 


ing  in  its  effect,  and  producing  relaxation  of  spasm.  Electric 
friction  by  the  roller  gives  a  shower  of  stinging  sparks  and  so 
resembles  the  spark.  It  gives  intense  cutaneous  stimulation, 
but  no  penetration.     It  is  followed  by  redness  of  the  skin. 


m. 


© 


Fig.  29.  —  Electrodes  for  static  machine. 

The  care  of  the  machine  and  the  technique  of  the  various 
forms  of  treatment  are  too  complicated  for  a  handbook  of  this 
length.  The  reader  is  referred  to  standard  works  for  further 
particulars.  They  are  not  taken  up  here,  because  the  ma- 
chines are  not  in  general  use,  except  in  special  hospitals,  and 
by  specialists.  They  do  not  form  part  of  a  standard  equip- 
ment for  convalescent  hospitals. 


CHAPTER   IV 
RADIANT   LIGHT   AND   HEAT 

The  sun's  rays  have  always  been  used  as  a  curative  agent. 
If  they  be  passed  through  a  prism  to  divide  them  into  the 
colors  of  the  spectrum,  they  will  be  found  to  extend  above 
and  below  the  range  of  visibility.  The  infra-red  rays,  with 
a  low  frequency  of  vibration,  give  out  heat  and  penetrate 
the  tissues  of  the  body  deeply.  The  ultra-violet,  with  a 
high  frequency  of  vibration,  are  mainly  instrumental  in 
producing  the  cutaneous  irritation  known  as  sunburn.  All 
artificial  sources  of  light  contain  these  heat,  light,  and  ultra- 
violet or  actinic  rays  in  varying  proportions.  The  arc 
light  is  rich  in  actinic  rays ;  the  incandescent  is  rich  in  heat 
rays.  By  passing  through  a  screen  of  red  glass  the  actinic 
rays  can  be  cut  out  and  by  using  a  violet  screen  the  effect  of 
the  heat  rays  can  be  diminished,  a  result  that  can  be  ob- 
tained equally  well  by  a  douche  of  cold  air  on  the  part. 

The  electric  arc  light  most  nearly  approaches  sunlight 
and  can  produce  an  erythema  just  like  sunburn,  and  when 
repeated  daily  a  definite  pigmentation  of  the  skin  like  tan- 
ning. It  has  a  marked  bactericidal  action  which  makes  it 
especially  useful  for  many  skin  diseases.  The  light  is  ap- 
plied by  the  solar  therapeutic  lamp,  mounted  upon  a  portable 
stand  (see  figure),  and  adjustable  for  position,  distance,  and 
strength  of  current.  To  apply  it,  the  patient  is  seated  and 
the  lamp  adjusted  to  the  part  to  be  treated.  The  current 
is  thrown  on  and  regulated  by  a  rheostat  starting  at  the 

37 


38 


RECLAIMING   THE  MAIMED 


minimum  intensity.     The  treatment  should  not  last  more 
than  one  or  two  minutes  at  first  and  will  be  followed  by 


\4 


< 


reddening  of  the  skin.     The  length  of  time  for  the  treatment 
can  be  increased  with  tolerance  just  like  exposure  to  the  sun, 


RECLAIMING   THE  MAIMED  39 

the  effect  is  counterirritant,  and  is  useful  for  referred  pains, 
neuralgia,  rheumatic  pains,  and  skin  infections.  The  treat- 
ment of  joints  requires  deep  penetration  and  for  this  purpose 
a  light  with  more  heat  and  fewer  actinic  rays  is  to  be  preferred ; 
but  it  must  always  be  borne  in  mind  that  all  three  are  present 
in  most  of  the  lights  that  are  in  general  use. 

Radiant  heat  causes  a  dilation  of  the  surface  capillaries 
drawing  the  blood  out  from  the  deeper  parts.  This  is 
succeeded  by  a  contraction  of  the  superficial  and  dilation 
of  the  deeper  vessels,  so  that  the  flow  of  blood  to  the 
part  is  stimulated  just  as  in  diathermy. 

The  masseuse  who  first  heats  the  limb  is  thus  able  to  work 
on  a  part  already  flushed  with  blood  instead  of  pumping 
it  in  by  massage,  and  the  beneficial  effect  is  increased  directly 
with  the  increased  volume  with  which  she  starts,  for  the 
exchange  in  the  circulation  will  be  correspondingly  hastened. 
The  athletic  trainer  who  would  send  a  runner  or  jumper 
out  for  a  contest  without  first  warming  up  the  muscles  would 
run  the  risk  of  having  him  pull  a  tendon  or  rupture  a  muscle, 
and  preliminary  massage  to  heighten  the  circulation  in  the 
muscular  tissue  is  the  best  preventive  of  such  an  accident, 
especially  if  it  is  continued  by  putting  on  a  warm  woolen 
covering  to  retain  the  heat. 

The  heating  of  a  part  in  all  cases  where  the  circulation 
is  lowered  is  essential  before  other  treatment  is  undertaken. 
Scar  tissue  has  poor  circulation  at  best,  and  frequently  the 
toothache-like  pain  in  it  is  relieved  by  raising  the  tempera- 
ture and  improving  the  local  circulation  alone.  In  all  cases, 
weakened  and  impaired  muscles  should  first  be  flushed  by 
blood  before  having  the  massage  and  active  movements 
that  complete  their  treatment.  Certain  superficial  scars 
become  sodden  and  tender  if  wet  heat  is  applied,  so  that  dry 
radiant  heat  is  especially  indicated  for  them. 

The  most  convenient  form  for  giving  a  local  treatment 
consists  of  a  lamp  of  about  60  c.p.,  contained  in  a  metal  cone 


40 


RECLAIMING   THE   MAIMED 


lined   with   a   metallic   reflecting   surface.     This   is   moved 
back  and  forth  or  in  circles  a  few  inches  from  the  surface, 


t^ 


S 


O 


until  the  temperature  of  the  part  is  sufficiently  raised  as 
shown  by  reddening  of  the  surface.    Care  must  be  taken  to 


RECLAIMING    THE  MAIMED 


41 


avoid  scorching  the  skin,  where  the  part  is  anaesthetic.  The 
patient  will  see  to  that  if  the  sensation  is  normal,  and  the 
treatment  should  never  be  carried  to  the  point  of  extreme  dis- 
comfort, nor  should  it  be  continued  more  than  three  or  or  four 
minutes.  Toleration  is  increased  by  moving  the  lamp  about. 
The  first  dilation  of  the  surface  capillaries  is  what  is  wanted. 
The  second  form  is  called  the  local  electric  light  bath. 
This  is  composed  of  six  or  twelve  i6  c.p.  lights  contained 
in  a  reflector,  so 
placed  in  relation  to 
the  part  that  a  con- 
stant temperature 
can  be  maintained. 
It  is  important  that 
there  shall  be  an 
even  distribution  of 
light  and  heat  over 
the  entire  area,  that 
a  wide  range  of  con- 
trol be  allowed  from 
a  low  graduated  heat 
continued  for  fifteen 
to  twenty  minutes 
to  the  most  intense 
that  can  be  borne. 
It   should    be    light 

and  portable  and,  in  every  case,  the  operator  should  be  able 
to  observe  and  regulate  the  temperature  by  means  of  a  ther- 
mometer. The  limit  of  temperature  in  these  baths  is  about 
1 80°,  although,  if  ventilation  is  allowed  and  the  air  kept 
dry,  the  temperature  can  go  up  as  high  as  300°.  This  form 
is  used  when  we  want  to  get  more  than  a  surface  effect  in 
myalgia  and  rheumatic  joints.  In  all  cases,  the  heat  should 
be  put  on  gradually  and  reduced  gradually,  and  the  treat- 
ment should  not  last  more  than  twenty  minutes. 


Fig.  32. — Local  bath  adjustable  and  with 
thermometer.  — Burdick. 


42  RECLAIMING   THE   MAIMED 

The  third  form  is  a  full  electric  light  bath.  Apparatus 
is  constructed  so  that  this  bath  may  be  given  with  the 
patient  in  bed  (see  illustration).  By  combining  two  of  these 
appliances,  we  can  make  a  cabinet  in  which  the  patient  may 
be  seated.  This  cabinet  contains  forty  to  fifty  i6  c.p. 
incandescent  lights.     A  thermometer  enables  the  operator 


Fig.  2>2>-  —  Full  electric  light  bath  for  a  bed  case.  —  Burdick. 

to  regulate  the  temperature,  and  the  whole  body  is  placed 
within  the  cabinet  except  the  head.  The  temperature  is 
raised  to  about  ioo°  before  the  patient  enters  and  the  current 
gradually  increased  until  i6o°  or  i8o°  is  reached,  cold  water 
compresses  are  applied  to  the  head,  and  the  patient  should 
drink  water  during  the  treatment  to  promote  sweating.  If 
fainting  threatens,  the  treatment  must  be  stopped ;  and  if, 
at  any  time,  the  patient  feels  faint,  the  pulse  should  be 


RECLAIMING   THE  MAIMED 


43 


counted  and  the  treatment  stopped  if  it  rises  above  120. 
This  bath  should  last  from  thirty  to  forty  minutes.  The 
patient  then  leaves  the  cabinet,  takes  a  warm  sponge  bath, 
and  rests  between  blankets  for  at  least  half  an  hour.  They 
should  not  be  given  more  than  twice  or  three  times  a  week. 
The  effects  of  these 
baths  are,  first,  red- 
ness of  the  skin ; 
second,  a  profuse 
perspiration ;  third, 
acceleration  of  the 
pulse,  which  should 
remain  strong  and 
regular  throughout 
the  treatment  ; 
fourth,  rise  of  tem- 
perature during  the 
treatment,  which 
falls  to  normal  after ; 
fifth,  increase  of 
elimination,  both  by 
the  lungs  and  kid- 
neys. They  should 
not  be  followed  by 
a  feeling  of  lassi- 
tude. They  are  of 
great  value  in  all 
forms  of  intoxica- 
tions,    alcoholic, 

rheumatic,  gouty,  and  nephritic,  and  relieve  congestion  of 
abdominal  organs,  like  the  liver,  spleen,  and  kidneys. 

Steam  Compresses.  —  Dry  heat  without  light  can  be 
applied  locally  by  Kellogg's  apparatus,  the  electrothermo- 
phore,  hot  water  bags,  or  hot  salt  or  sand ;  and  the  elec- 
tric light  can  be  applied  to  give  moist  heat  as  well,  through 


^B 

n 

■ 

^^1 
^^^^1 

WKm  T 
r \ 

'1 

i    'H 

Fig.  34.  —  Cabinet  bath  made  by  combining  two 
appliances  as  shown  in  Figure  33.  • —  Burdick. 


44  RECLAIMING   THE  MAIMED 

the  steam  compress,  which  consists  of  a  container  with  air- 
tight covering,  in  which  is  placed  a  Hnen  pad  wrung  out  of 
cold  water.  This  is  placed  on  the  part  to  be  treated,  and  the 
local  heat  bath  is  placed  over  it  until  the  compress  is  brought 


Fig.  35.  —  Kellogg's  thermophore. 

to  the  desired  temperature,  where  it  can  be  kept  indefinitely 
without  changing.  The  advantage  of  this  over  the  old 
method  of  wringing  cloths  out  of  hot  water  will  be  at  once 
apparent. 


CHAPTER  V 
HYDROTHERAPY 

Hydrotherapy  has  the  additional  resource  of  cold  as 
well  as  heat,  and  like  radiant  heat  it  can  be  applied  to  the 
whole  body  or  to  a  single  part.  Most  wounded  men  are 
quite  sound  except  for  the  injury  to  a  leg  or  arm  and  require 
treatment  for  that  only. 

In  these  cases  its  great  field  is  in  preparing  the  part  for 
treatment  by  massage,  stretching,  and  reeducation.  The 
cases  that  derive  most  benefit  are  healed  wounds  with  great 
areas  of  contracted  scar  tissue  —  painful  stumps  and  weak 
and  stiffened  joints  in  which  the  circulation  is  far  below 
normal.  After  treatment  for  twenty  minutes  by  whirling 
water  at  no  to  115°,  the  cold,  blue,  painful  limb  becomes 
red  and  warm,  and  the  apprehension  of  the  patient  to  any 
form  of  manipulation  disappears  under  the  feeling  of  well- 
being  and  comfort  that  results.  Spasm  disappears,  and  the 
part  becomes  soft  and  relaxed.  Masseurs  unite  in  declaring 
that  muscles  and  joints  are  then  more  easily  manipulated, 
a  judgment  in  which  the  patients  themselves  heartily  con- 
cur. Slight  adhesions  can  frequently  be  broken  down  with- 
out pain  and  function  quickly  restored.  Irritable  bruised 
nerves,  however,  may  be  made  more  irritable  by  this  method, 
and  the  temperature  should  then  be  not  more  than  100,  nor 
should  it  be  followed  by  any  manipulation.  The  warmth 
of  the  water  should  here  act  as  a  poultice  to  soothe  the  pain. 

4.^ 


46 


RECLAIMING   THE  MAIMED 


A  sort  of  gymnastics  for  the  circulation  can  be  given  by 
dipping  a  limb  alternately  in  hot  water  which  dilates,  and 
cold  which  contracts,  the  capillaries.  The  vessel  walls  are 
thus  exercised  and  their  tone  trained  to  respond  to  the  normal 
stimuli  of  heat  and  cold. 

For  general  treatment,  water  is  also  used,  hot  or  cold. 
The  man  who  is  tired  out  finds  himself  restored  to  vigor  by 
getting  into  a  hot  bath.  The  blood  is  drawn  out  to  the  sur- 
face from  the  brain  and  abdomen  and  the  whole  circulation 
redistributed,  but  here  again  it  must  not  be  continued  past 
the  first  flush,  otherwise  there  is  a  rapidly  increasing  debility. 


PULS£ 
KATE. 

IZO 


110 


too 


90 


80 


70 


-^^=^=====F= 


/i' 


sT 


pna. 


J 'If 


rd. 


4-_ 


ih 


^th. 


6^J'  Week. 


Fig.  36.  —  Average  pulse  rates  of  ten  cases  of  disordered  action  of  the  heart 
during  six  weeks'  treatment  by  the  pool  bath  at  Heaton  Park.  —  Dr.  Frank 
Radcliffe. 


RECLAIMING    THE   MAIMED  47 

One  evening  after  a  long  drive  I  plunged  into  a  thermal 
mountain  spring  at  about  ioo°  and  swam  in  it  for 
ten  minutes,  sometimes  with  my  head  under  water.  No 
cold  shower  was  taken  to  follow,  and  the  result  was  a  head- 
ache, suffused  eyes,  a  sleepless  night,  and  an  assiduous  use 
of  the  pocket  handkerchief  for  the  next  twenty-four  hours. 
This  illustrated  the  results  of  neglecting  to  secure  the 
necessary  reaction. 

As  soon  as  the  flushing  of  the  surface  is  obtained  the  pa- 
tient should  be  removed  and  a  cold  shower  taken  to  get  a 
good  reaction,  or  the  patient  put  to  bed  with  the  room  at 
an  even  temperature  till  the  vessels  regain  their  equilibrium. 

For  conditions  following  shell  shock,  irritable  heart, 
hallucinations,  fearful  dreams,  and  neurasthenia,  the  general 
poultice  of  a  bath  at  94°,  kept  up  for  an  hour  or  more  is 
hard  to  beat.  This  has  long  been  recognized  in  the  treat- 
ment of  mania  in  the  insane,  and  the  conditions  are  suffi- 
ciently close  to  form  an  analogy. 

Water  is  a  good  conductor  of  electricity,  so  that  this  agent 
may  be  applied  through  a  local  or  general  bath,  as  already 
described  in  Chapter  II. 

The  hydro  therapeutic  equipment,  necessary  for  the  treat- 
ment of  disabled  men,  consists  of  a  douche  and  shower, 
immersion  tubs,  or  a  pool  for  water,  kept  at  a  constant  tem- 
perature, local  baths  for  the  treatment  of  arms  and  legs,  and 
electric  baths  for  both  local  and  general  application. 

The  Douche.  —  The  douche  should  have  a  powerful  jet, 
the  stimulant  effect  of  the  water  being  increased  by  its 
force  which  may  go  up  to  thirty  pounds. 

A  treatment  should  always  begin  by  warm  water  (90°), 
rising  to  hot  (115°)  and  ending  with  cold  (60)°.  It 
should  not  last  more  than  one  or  two  minutes,  and, 
where  the  stimulant  effect  must  be  great,  the  Scottish 
douche  should  be  applied.  In  this  two  jets,  one  at 
100  degrees  and  the  other  at  60  degrees,  are  applied  alter- 


48 


RECLAIMING   THE  MAIMED 


nately  by  a  lateral  sweep  of  the  nozzle  up  and  down  the  spine. 
This  plan  is  also  used  in  the  local  contrast  baths  of  Robert 
Jones  for  exercising  the  circulation  of  an  arm  or  leg.  The 
shower  is  a  gentler  form  of  this  treatment  in  which  the 


RECLAIMING    THE   MAIMED 


49 


massage  of  the  water  jet  is  absent,  but  the  same  rules  apply 
to  it  as  to  the  douche. 

Immersion  Baths.  —  Immersion  baths  are  given  at  three 
temperatures,  below,  at,  and  above  the  skin  temperature. 
The  bath  at  94  degrees,  skin  temperature,  is  soothing  in 
character,  a  good  sedative.     Its  greatest  use  is  in  decreasing 


Fig.  38.  — The  pool  bath  at  Heaton  Park.     Capacity  twelve 
men.     Temperature  of  the  water  94°. 


nervous  irritability,  in  whatever  form  it  may  be,  and  in  sooth- 
ing a  disordered  heart.  After  one  hour's  immersion  the 
patient  should  be  wrapped  up  and  allowed  to  rest  for  another 
hour.  The  relief  from  the  constant  and  insidious  irritation 
of  clothing  and  movement,  and  the  support  of  a  medium  of 
about  the  same  specific  gravity  as  the  body,  doubtless  ac- 
counts for  much  of  the  benefit. 

The  hot  bath  (98  to  no  degrees)  dilates  the  peripheral 
vessels  and  increases  the  frequency  of  the  pulse.     Its  merit 


50 


RECLAIMING    THE   MAIMED 


is  founded  on  its  stimulant  effect  on  the  circulation.  The 
blood  is  drawn  out  to  the  surface,  which  becomes  red  and 
warm.  The  effect  is  somewhat  the  same  as  the  cabinet  bath, 
without  the  perspiration,  and  it  is  of  special  use  in  the  treat- 
ment of  fatigue  and  also  in  chronic  conditions  in  which  the 
general  circulation  is  sluggish.  The  immersion  should  be 
very  brief,  not  more  than  five  or  ten  minutes,  and  should  be 
followed  by  a  cold  shower  to  restore  the  tone  of  the  dilated 
vessels,  and  the  patient  should  be  wrapped  up  and  put  to 
bed  for  an  hour. 

Local  Baths.  —  The  whirlpool  baths  have  proved  their 
value  in  the  after  treatment  of  wounds,  during  the  present 


% 


f 


Fig.  39.  —  Two  arm  and  one  leg  whirlpool  baths.     Heaton  Park. 

war,  and  are  widely  used.  The  arm  or  leg  is  thrust  into  a 
vessel  containing  water  at  a  temperature  varying  from  105 
up  to  115  degrees.  This  water  is  circulated  by  means  of 
jets  set  at  an  angle  or  by  a  propeller.  Air  is  also  introduced, 
so  that  the  limb  is  immersed  in  a  swirling,  bubbling  current. 
In  this  way  the  part  is  flushed  with  blood,  and  the  full  effect 


RECLAIMING    THE   MAIMED  51 

of  heat  is  obtained  in  a  way  that  is  impossible  if  the  water 
is  still.  The  air  bubbles-  increase  the  stimulant  effect  on 
the  skin.  They  are  peculiarly  adapted  to  the  treatment 
of  painful  stumps,  painful  scar  tissue,  partial  paralysis, 
injuries  to  nerves,  and,  in  fact,  to  any  condition  which  lowers 
the  circulation  and  nutrition  of  the  part.  The  period  of 
immersion  is  about  twenty  minutes,  and  with  increased 
toleration,  it  may  be  possible  to  raise  the  temperature  as 
high  as  1 20  degrees.  Great  caution  must  be  used  to  prevent 
scalding,  especially  if  any  area  of  anaesthesia  is  present. 
It  makes  the  best  preparation  for  massage  and  manipulation 
in  cases  where  the  limb  is  cold,  blue,  and  painful.  Movements 
and  manipulations  can  then  be  performed  which  would  not 
be  tolerated  by  the  patient  without  this  preparation. 

Contrast  Baths.  — -  The  contrast  bath  is  a  form  of 
gymnastics  for  the  circulation,  which  is  like  the  Scottish 
douche  in  its  effect.  It  consists  of  two  oblong  baths,  placed 
side  by  side,  one  supplied  with  water  at  a  temperature  of 
no  degrees,  the  other  supplied  with  water  at  60  degrees. 
The  patient  dips  the  hand  or  foot  alternately  in  these  baths, 
leaving  it  in  for  about  two  minutes.  They  are  applied  to 
all  conditions  in  which  the  local  circulation  requires  stimula- 
tion. 

Electric  Baths.  —  The  use  of  a  glass  or  porcelain  vessel 
made  to  contain  an  arm  or  a  leg  permits  the  use  of  electricity 
and  ionic  medication  through  the  medium  of  water.  The 
vessel  must  not  be  metallic  or  a  conductor.  Water  at,  or 
slightly  above,  the  skin  temperature  is  used,  and  an  electrode 
of  copper  or  carbon  is  placed  in  the  water  at  one  end  and  the 
indifferent  electrode  applied  to  some  part  of  the  body  by  a 
large  pad.  The  polarity  is  determined  unless  the  sinus- 
oidal current  is  used,  and  the  current  turned  on  till  a  tin- 
ghng  sensation  is  felt.  It  is  afterwards  increased  with  added 
toleration.  Twitching  of  the  muscles  can  be  obtained  by 
rhythmical  interruptions  of  the  current,  and  the  laws  govern- 


52 


RECLAIMING    THE   MAIMED 


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RECLAIMING    THE   MAIMED  53 

ing  ionization  already  described  would  apply  (Chapter  II). 
The  entire  current  passes  through  the  limb  from  or  to  the 
indifferent  pole,  and  in  this  the  unipolar  local  bath  differs 
from  the  general  electric  bath.  Various  combinations  are 
made  of  arm  and  leg,  right  and  left,  by  the  Schnee  baths, 
which  come  complete  with  switchboard  and  commutator. 

In  the  immersion  bath,  which  must  be  carefully  insulated, 
two  large  copper  electrodes  are  inserted,  one  at  either  end. 
They  are  protected  so  that  they  cannot  be  touched  by  the 
patient.  The  bath  is  filled  with  water  at  loo  degrees,  the  pa- 
tient immersed,  and  the  current  turned  on  slowly.  The  pa- 
tient should  be  conscious  of  a  pleasant  tingling  sensation.  The 
period  of  immersion  should  begin  at  1 5  minutes  and  go  up  to 
30.  The  current  is  slowly  turned  off  before  the  patient  leaves 
the  water  to  take  a  half  hour's  rest,  well  wrapped  up.  It 
is  probable  that  not  more  than  one  tenth  of  the  current  passes 
through  the  patient ;  the  rest  goes  through  the  water. 

The  bath  should  not  be  of  metal.  If  the  current  is  from 
the  main,  it  must  be  carefully  insulated  from  the  waste  pipe. 
Taps  and  switches  must  be  out  of  the  patient's  reach,  and 
additional  water  added  from  a  jug.  In  fact,  owing  to  the 
necessary  precautions,  this  bath  is  not  recommended  except 
under  most  skilled  supervision  in  special  hospitals. 

It  is  used  for  neurasthenia  and  debility,  and  the  current 
employed  is  the  sinusoidal  or  galvanic. 

Medicated  Baths.  —  In  most  of  the  spas,  medicated 
baths  can  be  obtained.  These  are  taken  up  in  the  full  de- 
scription of  each  spa.  They  are  saline,  sulphur,  or  iron,  and 
can  be  prepared  artificially. 

A  shower  or  douche  is  frequently  given  combined  with 
massage  and  manipulation  carried  along  under  water,  the 
patient  reclining  in  a  hollow  table  bath.  Its  value  is  not 
great  enough  to  make  it  worth  while  to  install  the  expensive 
and  complicated  apparatus  necessary. 


CHAPTER  VI 

MASSAGE   AND    PASSIVE    MOVEMENT 

Massage  in  its  many  forms  is  used  to  dissipate  effusions 
after  sprains,  to  soften  and  stretch  contracted  scars  or  ad- 
hesions, to  prevent  atrophy  and  contractures  following  nerve 
injuries  and  fractures,  to  stimulate  the  circulation  after 
frostbite,  and  to  improve  general  nutrition  in  local  and 
general  rheumatism.  It  is  of  great  value  as  a  preliminary  to 
operation  to  loosen  scars  and  make  operation  easier,  and  to 
excite  inflammatory  action  about  a  sequestrum  and  help  to 
expel  it,  or  to  diagnose  any  lurking  infection  in  an  old  wound. 

Aimless  rubbing  is  as  useless  as  waving  a  palm-leaf  fan,  if 
the  operator  be  weak  and  timid,  but  it  has  the  additional 
possibilities  of  doing  much  harm  if  the  operator,  besides  being 
ignorant,  is  rough  and  strong.  Sometimes  massage  is  of 
value  when  passive  movement  is  contraindicated,  and  of  the 
manipulations  of  massage  themselves,  tapotement  may  be 
effective  when  effleurage  would  be  useless,  as  will  appear. 

Efffeurage  is  essentially  a  surface  manipulation.  It  forms 
the  beginning  of  treatment  in  all  painful  conditions  like 
sprains,  fractures,  or  after  breaking  down  adhesions.  It  is 
a  preparation  for  more  active  manipulations.  The  hand  is 
passed  lightly  over  the  skin,  like  stroking  a  cat,  usually  from 
the  periphery  to  the  center.  It  is  performed  by  the  palm  of 
the  hand,  the  thumb,  or  the  finger  tips.  Both  hands  are 
used  for  large  fleshy  parts  like  the  buttock,  thigh,  chest, 
back,  or  neck ;    the  thumb  or  finger  tips  are  employed  around 

54 


RECLAIMING    THE   MAIMED  55 

bony  parts  like  the  hand,  ankles,  wrist,  forehead,  and  scalp, 
and  about  adherent  scars ;  the  fingers  adapting  themselves 
to  the  part  worked  upon.  If  properly  done,  it  should  act  as  a 
sedative  to  pain  ;  and  when  the  fears  of  the  patient  have  been 
stilled,  friction  may  be  made  vigorous  enough  to  act  upon 


Fig.  41.  —  EiSeurage  of  the  arm. 

the  deeper  structures  and  wake  up  the  sluggish  circulation  in 
and  about  the  seat  of  trouble. 

In  petrissage  or  kneading,  the  skin  moves  with  the  hand 
like  a  glove.  It  is  done  with  the  thumb  opposed  to  the  hand, 
the  fingers  opposed  to  the  palm,  or  the  two  hands  opposed  to 
one  another.  The  muscles  are  rolled  under  the  hand  and 
skin,  and  intermittently  pressed  against  the  underlying  bone. 
It  is  slow  and  deep,  usually  following  the  course  of  the  venous 
circulation.     This  manipulation  should  be  firm,  but  not  too 


56 


RECLAIMING   THE   MAIMED 


painful,  —  persistent  pain  following  treatment  means  either 
a  clumsy  operator  or  a  condition  that  should  not  be  massaged. 
It  is  most  useful  for  stretching  adherent  scars,  for  removing 
the  products  of  fatigue  or  effusions,  and  for  improving  the 
blood  supply.     It  is  the  main  manipulation  used  in  general 


Fig.  42.  —  Kneading  the  calf  muscles. 


treatment  for  rheumatism,  fibrositis,  or  lowered  circulation 
from  any  cause. 

Tapotement  or  striking  is  a  surface  and  also  a  deep  manipu- 
lation. It  consists  of  slapping  with  the  open  hand,  hacking 
with  the  ulnar  border  of  the  hand,  using  the  tips  of  the  fingers 
like  a  flail,  or  beating  with  the  fiat  of  the  clenched  knuckles. 
The  blows  should  be  sharp  and  quick,  short  and  snappy,  done 
from  a  loose  wrist,  but  not  heavy  enough  to  bruise.  The 
main  action  is  stimulation  of  the  superficial  nerves.  The 
vessels  dilate  and  the  part  becomes  reddened.  If  repeated 
long  enough  and  strongly  enough,  sensation  is  dulled. 


RECLAIMING    THE   MAIMED  57 

Vibration  is  a  rapid  form  of  tapotement,  in  which  the  rate 
of  the  strokes  runs  from  500  to  5000  to  the  minute,  and  is 
best  performed  by  a  machine  for  the  purpose,  with  the 
various  forms  of  applicators  for  the  different  regions.  Vi- 
bration is  followed  by  a  feeling  of  numbness,  then  tingling, 
and  then  warmth,  so  that  its  general  effect  is  stimulation. 


Fig.  43.  —  Hacking  with  ths  ulnar  border  of  the  hands. 

Always  plan  beforehand  the  choice  and  sequence  of  these 
procedures  in  a  treatment,  and  do  not  continue  one  manipula- 
tion more  than  four  or  five  minutes  over  one  region.  It 
should  then  be  interrupted  and  replaced  by  another  pro- 
cedure, but  a  definite  sequence  thought  out  and  maintained. 
Limit  your  conversation  with  the  patient  to  the  giving  of 
directions  and  don't  let  the  treatment  degenerate  into  a 
social  visit  accompanied  by  the  aimless  rubbing,  pulling,  and 
twisting  of  a  limb,  which  too  often  goes  by  the  name  of 
massage. 


58 


RECLAIMING   THE  MAIMED 


The  surface  to  be  treated  should  be  scrupulously  clean,  and 
should  not  be  greased  or  oiled,  except  occasionally  about  a 
tough  and  irritable  scar.     The  part  may  be  dusted  with 


Fig.  44.  —  The  vibrator  in  use. 

talcum  powder,  and  a  very  hairy  surface  may  even  be  pro- 
tected from  irritation  by  manipulation  through  a  silk  or 
cotton  undergarment. 

A  stiffened  joint  or  painful  scar  should  be  prepared  for 
massage  by  heat  in  the  form  of  baths  of  running  water  at 
about  no  degrees  for  thirty  minutes,  or  by  exposure  to 
radiant  heat  until  it  is  thoroughly  reddened.  Where  these 
are  not  available,  it  may  be  packed  in  hot  sand  or  salt,  — 
anything  that  will  flush  the  part  with  blood  greatly  assists 


RECLAIMING    THE   MAIMED  59 

in  making  possible  massage  and  manipulation  that  would 
otherwise  be  too  painful. 

In  sprains,  or  after  breaking  down  adhesions,  which  is  the 
same  thing,  massage  should  be  given  at  once,  beginning  with 
efifleurage  and  continued  by  kneading,  alternating  these  two 
procedures  until  the  whole  region  has  been  covered,  and  sup- 
porting the  ankle  or  elbow  between  treatments  by  a  bandage 
over  cotton  wool  to  exert  elastic  pressure.  In  certain  frac- 
tures the  splint  may  be  removed  for  treatment  as  early  as  the 
third  day  and  effleurage  given  above  and  below  the  seat  of 
fracture.  The  technique  is  too  complicated  to  go  into  here, 
but  is  fully  described  in  Mennell's  book  on  massage.^  Stumps 
of  limbs  remaining  after  amputation  should  be  prepared  by 
heat,  given  effleurage  kneading  and  vibration  to  improve 
nutrition  and  promote  absorption  of  scar  tissue ;  and  where 
necessary,  contractures  should  be  stretched,  followed  by 
movement  and  exercise  for  reeducation. 

Red  in  a  painful  scar  is  the  color  signal  of  danger  for  the 
masseur  who  intends  to  stretch  it.  It  means  that  there  is  a 
network  of  vascular  loops  whose  thin  walls  are  easily  torn, 
that  will  bleed  and  form  new  scar  tissue  if  roughly  handled, 
leaving  that  man's  last  condition  worse  than  his  first.  Treat- 
ment must  begin,  in  such  cases,  with  effleurage,  light  circular 
friction,  and  kneading  of  the  neighboring  tissue. 

Scars  may  not  show  their  true  character  on  the  surface. 
An  innocent  looking  surface  scar  will  often  show  a  slight 
dimple  which  is  deepened  by  any  voluntary  movement  of 
the  muscles,  and  dissection  would  show  that  it  has  spread  out 
its  tentacles  deep  into  the  surrounding  tissue,  strangling  in 
its  grasp  nerves  and  vessels,  and  adhering  tenaciously  to  bone 
and  muscle  far  from  its  apparent  place.  Persistent  pain 
following  treatment  always  means  too  much  force.  Some 
patients  wince  on  the  slightest  touch,  but  this  false  pain  must 
be  distinguished  from  real  and  persistent  variety.     Slowly 

^  Massage,  its  Principles  and  Practice.    J.  B.  Mennell. 


60  RECLAIMING   THE   MAIMED 

and  gradually  increase  the  pressure  or  tension,  and  at  the 
same  time  distract  the  patient's  attention.  This  will  fre- 
quently serve  to  make  the  diagnosis  clear. 

Massage  may  be  used  to  assist  in  removing  a  sequestrum 
or  foreign  body.  A  red  spot  appears  over  the  site  of  per- 
sistent pain,  the  skin  opens,  and  the  dead  bone  is  extruded 
more  rapidly  than  if  left  to  unaided  Nature.  After  wounds 
by  high  explosives  or  shrapnel,  it  is  a  frequent  experience  to 
thus  bring  to  the  surface  and  extrude  bits  of  belt  buckle, 
shreds  of  cloth,  or  fragments  of  shell.  Here  the  pain  follow- 
ing treatment  will  be  continual  until  the  disturbing  cause  is 
discharged,  but  the  masseur  is  here  assisting  Nature  in  her 
work  of  elimination.  Such  cases  require  the  most  careful 
supervision,  and  if  inflammation  becomes  intense  or  wide- 
spread, stop  until  it  has  quieted  down. 

General  massage  is  best  given  at  an  hour  midway  between 
meals,  and  never  immediately  after  a  meal.  The  seance 
should  last  from  thirty  to  forty  minutes  and  be  followed  by 
a  rest.  The  limbs  should  be  taken  in  sections,  and  the 
general  direction  of  the  manipulations  be  directed  from 
extremity  to  center. 

Passive  Movement.  —  Passive  movement  is  used  to 
stretch  contracted  scars,  to  increase  the  range  of  movement 
in  stiffened  joints,  to  rehearse  the  movements  of  joints  whose 
muscles  are  paralyzed  or  weakened  and  thus  detect  or  pre- 
vent contractures.  It  does  not  always  accompany  massage, 
and  may  be  contraindicated  as  in  some  fractures  or  im- 
perfectly healed  wounds.  It  may  be  necessary  to  early 
them  out  with  the  limb  on  a  splint  to  keep  weak  muscles 
relaxed  and  free  from  strain,  —  the  dropped  wrist  or  foot 
may  have  to  be  kept  dorsi-flexed,  and  the  arm  with  deltoid 
paralysis  abducted. 

All  movements  should  be  don€  by  slow.  Insistent  pressure ; 
never  use  quick  or  jerky  motions  ;  they  frighten  the  patient, 
and  he  locks  the  joints  to  resist  the  attack.     Distract  the 


RECLAIMING    THE   MAIMED  61 

patient's  attention  from  the  movement  that  is  being  given, 
especially  in  functional  cases.  It  greatly  assists  in  getting  a 
fuller  range  of  movement,  and  suggestion,  deception,  en- 
couragement, scolding,  or  even  bullying,  all  have  their  uses 
in  such  cases.  Slight  adhesions  can  be  broken  down  with 
great  relief  by  this  means,  especially  if  the  part  has  been  well 
prepared  by  heat,  but  serious  or  firm  old  adhesions  should 
be  left  alone  or  broken  down  by  the  surgeon  under  an  anaes- 
thetic. After  such  an  operation,  for  the  breaking  down  of 
adhesions,  passive  movement  should  be  started  the  following 
day,  and  the  joint  moved  once  only  through  its  range.  This 
should  be  repeated  every  day,  and  the  limb  kept  at  rest  be- 
tween treatments.  Don't  make  a  pump  handle  of  such  an 
arm.  It  is  like  a  fresh  sprain,  and  must  be  given  a  chance 
to  become  quiet,  which  is  impossible  if  it  is  worried  inces- 
santly. In  all  cases  of  scars  and  contractures  in  which  pain 
persists  for  twelve  hours  after  treatment,  rest  the  joint  and 
fix  it  in  the  best  possible  position,  if  necessary  by  a  splint, 
until  the  pain  has  disappeared,  then  start  with  massage  only, 
without  movement,  given  after  adequate  preparation  by 
heat.  An  old  white  scar  can  be  stretched  only  by  continu- 
ous tension,  best  given  by  the  use  of  splints,  which  should 
be  worn  for  weeks  or  even  months  and  even  then  the  added 
movement  is  got  mostly  by  stretching  the  sound  tissue  that 
surrounds  it. 

Passive  movement  of  single  fingers  is  done  best  by  the 
operator's  hand,  the  joint  being  slowly  extended  and  flexed 
as  far  as  possible,  and  the  improvement  maintained  by  a 
splint  worn  between  treatments  if  necessary.  This  is  es- 
pecially true  of  functional  contractures  where  fixation  in  the 
correct  position  is  essential  until  the  patient  can  be  taught 
to  maintain  the  correct  position  himself. 

The  wrist  is  flexed,  extended,  adducted,  and  abducted,  by 
the  operator's  hand  passively  as  follows :  The  patient's  fist 
should  be  clenched  and  grasped  by  one  hand,  the  other  being 


62  RECLAIMING   THE  MAIMED 

used  to  steady  his  forearm.  The  movement  should  be  strong, 
firm,  and  slow. 

Pronation  and  supination  may  be  done  passively  by  the 
hand  of  the  operator,  seated  facing  him  and  grasping  the 
patient's  hand,  palm  to  palm,  the  patient's  arm  and  forearm 
being  kept  at  right  angles,  and  so  fixed  as  to  prevent  rotation 
of  the  shoulder.     It  is  the  old  game  of  twisting  wrists. 

Flexion  and  extension  are  performed  by  the  same  grasp 
of  the  hand,  and  from  the  same  position. 

Rotation  of  the  shoulder  is  performed  by  the  operator  as 
follows : 

The  patient  sits  with  the  arm  down,  the  forearm  flexed  at  a 
right  angle.  The  operator,  standing  behind  him,  grasps  the 
wrist  and  forearm  with  one  hand  and  the  shoulder  with  the 
other.  The  elbow  is  the  fixed  point,  and  the  wrist  is  used  as 
a  lever,  being  brought  out  and  in  slowly  without  changing  the 
angle  of  flexion  at  the  elbow. 

Circumduction  is  performed  by  seating  the  patient  on  a 
stool,  the  arm  stretched  straight  out  to  the  side,  the  operator 
standing  behind  with  one  foot  on  the  bench,  and  the  knee 
under  the  axilla  to  steady  the  shoulder,  which  is  also  held  by 
one  hand,  whilst,  with  the  other,  he  circumducts  the  shoulder 
by  grasping  the  arm  just  below  the  elbow.  Slight  adhesions 
may  be  broken  down  by  these  means,  not  only  without  in- 
jury, but  with  great  relief  to  the  joint,  but  any  persistent 
pain  after  treatment  warns  the  operator  of  the  necessity  for 
caution. 

Circumduction  of  the  ankle  is  done  by  the  hand,  but  full 
flexion  is  difficult  or  impossible  when  the  powerful  tendon 
Achilles  is  contracted,  and  a  preliminary  tenotomy  is  often 
indicated.     The  hold  for  this  purpose  is  shown  in  Fig.  45. 

Flat  foot  and  claw  foot  (pes  cavus)  are  often  treated  for 
long  periods  by  massage  and  passive  movement  without  re- 
sults. These  procedures  can  have  but  a  minor  place  in  the 
treatment  of  such  conditions,  and  they  should  be  referred 


RECLAIMING    THE   MAIMED 


63 


for  surgical  or  orthopedic  treatment  by  operation,  support, 
and  reeducation. 

Flexion  and  extension  at  the  knee  may  be  done  by  the 
hand,  the  patient  being  seated  with  the  leg  over  the  end  of  a 
plint  for  flexion,  or  lying  prone  on  a  plint  for  either  extreme 
flexion  or  full  extension.     The  hand  is  much  better  than  any 


Fig.  45.  —  The  hold  for  flexion  of  the  ankle  and  stretching  the 
tendo  Achillis. 


machine,  because  it  can  give  the  important  rotation  move- 
ment of  the  leg  upon  the  thigh  in  flexion  so  wefl  insisted  upon 
by  Sir  Robert  Jones.  At  the  end  of  each  complete  flexion  of 
the  knee,  twist  it  in  and  out. 

The  hip  can  be  extended,  flexed,  rotated,  adducted,  and 
abducted,  with  the  patient  supine  on  a  plint,  the  ankle  of 
the  side  to  be  moved  being  grasped  by  the  operator  by  one 
hand,  his  other  hand  placed  on  the  knee  of  the  same  leg,  and 
the  other  knee  drawn  up  to  a  right  angle.  The  hips  should 
be  strapped  in  place.  The  movement  of  the  thigh  can  then 
be  made  in  the  required  direction. 


64  RECLAIMING   THE   MAIMED 

Passive  movement  of  the  back  can  best  be  done  with  the 
patient  strapped  at  the  level  of  the  trochanters  prone  to  a  plint, 
with  the  body  projecting  over  the  end,  and  supported  by  an 
assistant  (leg  lying)  ;  the  trunk  can  then  be  flexed,  extended, 
or  rotated,  on  the  fixed  pelvis.  Rotation  can  also  be  given 
from  the  position  of  sitting  astride  the  plint  by  pressure  on 
one  shoulder  and  tension  on  another. 

Passive  movement  of  the  neck  in  all  directions  should  be 
done  by  the  hands  only,  and  with  the  greatest  caution,  the 
patient  lying  supine  on  the  plint,  with  the  head  projecting 
over  the  end. 


CHAPTER  VII 
ACTIVE   MOVEMENT   AND   REEDUCATION 

Active  Movements.  —  Active  movements  are  done  free 
or  with  apparatus,  and  are  for  correction,  reeducation,  and 
the  cultivation  of  strength  and  endurance. 

Free  movements  of  the  joints  need  not  be  described  in 
detail ;  they  are  simply  a  rehearsal  of  all  the  movements 
normal  to  each  joint ;  but  even  where  the  limb  is  still  in  a 
splint,  the  patient  may  learn  muscle  dancing  or  twitching 
the  muscles  without  moving  the  joint  until  they  become 
strong  enough  to  raise  the  dropped  wrist  from  its  dorsi- 
flexed  splint,  or  bend  the  stiffened  knee  and  so  reduce  the 
time  of  splintage. 

Principles.  —  Apparatus  is  necessary  to  bridge  the  gap 
between  free  movement  and  the  more  complicated  and  skill- 
ful coordination  of  gymnastics  and  occupation,  and  it  can 
be  constructed  so  as  to  give  a  graduated  and  measurable 
load,  to  be  increased  as  strength  returns.  Muscles  work 
better  against  resistance  than  free,  and  the  necessary  resist- 
ance may  be  given  by  the  hand,  by  friction,  forming  a 
brake  on  the  turning  of  a  wheel  or  handle,  by  stretching 
elastic  cords,  or  by  stretching  or  compressing  springs.  In 
these  devices,  it  is  difficult,  or  impossible,  to  measure  ac- 
curately the  work  done.  They  vary  at  different  stages  of 
the  movement,  are  uneven,  and  the  patient  quickly  tires 
and  becomes  discouraged,  because  he  cannot  see  a  definite 
and  measurable  improvement.  The  best  principle  to  use  is 
r  65 


66 


RECLAIMING    THE   MAIMED 


the  raising  of  graduated  weights,  either  by  a  lever  or  by  a 
rope  and  pulley.  In  the  former,  the  weight  is  clamped  on 
a  lever  at  points  indicated  on  a  scale,  the  lengthening  of  the 
lever  increasing  the  force  necessary  to  raise  it.  This  is  the 
principle  employed  by  Zander  in 
most  of  his  machines,  which, 
however,  are  expensive,  com- 
plicated, cumbrous,  require  much 
space,  and  need  an  engine  to 
supply  motive  power  for  some  of 
them.  Appliances  can  be  con- 
structed to  produce  accurately 
the  same  effects  at  one  tenth  the 
cost,  by  making  use  of  the  weight 
and  pulley. 

Figure  46  shows  diagrammati- 
cally  an  arrangement  by  which 
the  direction  of  the  resistance 
may  be  upward,  downward,  or 
from  the  side.  Machines  com- 
bining these  three  movements 
are  called  triplex,  or  triplicate 
machines,  but,  in  addition  to 
these,  special  devices  are  neces- 
sary for  exercising  certain  joints. 
The  following  set  of  appliances 
are  designed  to  combine  sim- 
plicity, cheapness,  and  efficiency. 
They  can  be  easily  multiplied  to 
any  extent  by  a  good  carpenter 
and  blacksmith  who  has  the 
pattern  before  him. 

Sequence. — Their  use  should 
have  a  place  in  a  definite  se- 
quence;   treatment   begins  with 


\ 

n 

<t 

C-<©4-. 

Fig.  46.  —  The  triplicate  pulley 
weight. 


RECLAIMING   THE  MAIMED  67 

the  preparation  of  the  Umb  or  joint  by  electricity,  radiant 
heat,  or  hot  baths,  then  massage  and  passive  movements, 
as  already  described,  followed  by  active  movement. 


Fig.  47.  —  Protractors  for  measuring  angles  of  movement  in  the 
shoulder,  elbows,  wrist,  knee,  and  ankle.     Hart  House. 


68  RECLAIMING   THE  MAIMED 

A  mirror  is  of  great  value  to  teach  accuracy  and  associate 
the  feeling  of  the  movement  with  its  appearance. 

Measurement.  —  Before  beginning  the  reeducation  of  a 
joint,  the  range  of  movement  should  be  carefully  measured. 


Fig.  49.  —  Small  protractor  for  measuring  the  angle  of  flexion 
in  fingers.     Hart  House.     Toronto. 

This  is  done  by  means  of  protractors  of  cardboard,  or  gal- 
vanized sheet  iron,  with  the  scale  marked  in  degrees.  The 
illustration  shows  the  method  of  measuring  movements  of 
the  shoulder  forward  and  backward,  the  protractor  being 


RECLAIMING    THE   MAIMED 


69 


set  with  zero  perpendicular  to  the  joint  as  checked  by  a 
plumb  line.  The  movement  in  either  direction  is  marked 
in  degrees.     The  elbow,  wrist,  knee,  and  ankle  are  measured 


Fig.  50.  —  Measuring  strength  of  grip  by  the  tycos  sphygmo- 
manometer. —  F.  W.  Harvey. 


70  RECLAIMING    THE   MAIMED 

by  the  second  protractor  made  of  galvanized  iron  strips, 
hinged,  and  with  a  scale  pasted  on  to  a  side  plate.  Figure 
49  shows  a  small  one  for  the  fingers. 

Most  of  the  appliances  about  to  be  described  have  protrac- 
tors attached,  so  that  the  range  of  movement  can  be  watched 
by  the  patient  himself,  during  the  exercise,  and  this  additional 
incentive  given  him  to  use  his  best  efforts.  The  measure- 
ment of  abilitv  to  repeat  movement  will  be  in  terms  of  weight 
raised  and  number  of  repetitions.  The  maximum  strength 
of  the  grip  can  be  taken  conveniently  by  partly  inflating  the 
cuff  of  a  tvcos  sphvgmomanometer  and  noting  the  height 
to  which  the  mercurv  is  raised  when  the  cuff  is  squeezed. 
This  is  quite  as  reliable  as  Amar's  Bulb,  and  is  better  than  the 
ordinarv  hand  dvnamometer. 

The  appliances  are  for  two  purposes,  stretching  and  im- 
proving the  strength.  All  the  stretching  movements  are 
kept  within  the  voluntary  control  of  the  patient,  who  can 
be  trusted  to  desist  before'danger  of  lacerating  firm  adhesions 
is  imminent.  The  appliances  for  improving  the  strength 
can  be  loaded  with  increasing  weights  as  the  power  to  lift 
them  returns  and  the  patient  can  be  interested  in  watching 
the  extent  of  each  movement,  as  shown  on  the  scale,  in  watch- 
ing the  rising  weight  as  it  is  lifted,  in  calculating  the  total 
amount  of  work  done  in  foot  pounds,  or  in  listening  to  and 
counting  the  clicks  of  the  ratchet  as  the  movement  is  made. 

The  operator  should  be  seated  opposite  the  patient  in 
all  hand  and  arm  exercises  on  the  table,  Fig.  48,  and  should 
regulate  the  machines  and  amount  of  work  done. 

Upper  Extremity.  —  i.  Finger  board.  —  (a)  For  stretch- 
ing contraction  of  the  fingers,  in  flexion,  and  (6)  for  stretch- 
ing abduction  at  the  metacarpophalangeal  joints. 

(a)  Extension  of  single  fingers:  The  fingers  are  placed  on 
the  board  in  moderate  flexion,  and  the  finger  under  treat- 
ment goes  up  the  stair,  step  by  step.  Note  the  last  step 
at  which  the  finger  under  treatment  can  be  raised  from  the 


,1 


i'f 


^1 


r} 


:f 


4itJ 


7,0    .Ififob^^U  laam"?  ,a    .aonJdOiianssail  ,K 


Fig.   . 

4,  Finger  machines.    B,  Finger  treadmill.    C,  Wrist  circvmiductor.    Z),  Wi 

G,  Creeping 


he  arm  table, 

ad  adductor.    E.  Wrist  mill  for  flexiou  and  extension.    F.  Pronator  and  supinator 
shoulder  abduction. 


RECLAIMING    THE   MAIMED 


71 


Fig.  51.  —  Finger  board  for  stretching  contractions  and  linger  flexions. 
Hart  House.     Toronto. 

step  without  assistance.     Depress  the  hand  to  stretch  still 
farther. 

ih)  Place  the  index  finger  against  the  peg  at  i  and  spread 
the  second  finger  out,  noting  the  farthest  point  at  which 


Fig.  52.  —  Finger  board  for  stretching  abduction  of  fingers.     Hart  House. 


72 


RECLAIMING   THE   MAIMED 


it  can  touch  the  peg.     Repeat  with  the  second,  third,  and 
fourth. 

Repeat  each  movement  not  more  than  five  times. 


Fig.  53.  —  Pulley  weights  for  exercising  fingers  in  flexion  and  extension,  right 
hand  doing  exercise  i,  left  hand  with  thumb  attachment  doing  abduction. 


The  patient  then  moves  to  the  next  five  apphances,  the 
operator  sitting  opposite. 

2.   Finger    pulleys.  —  For  flexion   and    extension    of  the 

fingers.    Strap  the  wrist  and  arm  at  the  elbow,  insert  the 


RECLAIMING   THE  MAIMED  73 

fingers  into  the  glove  stools  and  add  weight  until  it  can  barely 
be  lifted  by  the  voluntary  power  of  each  finger.  The  weights 
are  increased  as  improvement  goes  on,  and  the  movements 
repeated  up  to  the  point  of  exhaustion. 

ist  exercise  :  High  attachment.  Flex 
metacarpophalangeal  joints,  keeping  in- 
terphalangeal  rigidly  extended. 

2d    exercise:    Horizontal    attachment.               ^  '  ^^' 
Flex     interphalangeal     joints,     keeping    ip^hm^i^— ^ 
metacarpophalangeal  joints  extended.  '*^ 

3d    exercise :    Low    attachment.      Ex-  ^^^-  5S- 

tend  metacarpophalangeal   joints,  keep-  ^ 

ing  inter-phalangeal  extended.  ^\ 

4th  exercise :    Low   attachment.     Ex-  *\^ 

tend     metacarpophalangeal     and     flex  \ 

interphalangeal  joints.  : 

The  operator  seated  opposite  the 
patient  should  count  the  repetitions  and  ^^'  ^^' 

encourage  his  efforts.     Each  exercise  to  U*      •■    | 

be  continued  till  movement  shows  flag-  f** 

ging,  and  then  stopped.     The  most  con-  ; 

venient  weights  are  shot  bags,  loaded  to  }. 

two  ounces  each,  and  attached  by  hooks.  \ 

They  can  easily  be  made  and  repaired  fig.  57. 

by  the  masseuse. 

3.  Thumb  ad-  and  abduction.  —  Hsind  in  pronation. 
Attach  the  stool  on  the  radial  side  to  the  thumb  for 
adduction. 

ist  exercise :  Draw  the  thumb  across  the  hand.  Repeat 
the  movement  to  exhaustion. 

2d  exercise :  Attach  the  stool  on  the  ulnar  side  to  the 
thumb;  draw  the  thumb  out  in  abduction,  Fig.  53.  Repeat 
to  exhaustion. 

4.  Finger  treadmill.  —  For  voluntary  flexion  of  fingers. 
Strap  the  wrist  and  turn  the  wheel  by  flexing  the  fingers 


74 


RECLAIMING   THE   MAIMED 


in  turn  till  exhaustion  of  each  finger.  The  amount  of  work 
done  by  a  single  finger  can  be  calculated  by  using  that 
finger  only,  and  noting  the  weight,  and  the  distance  it  is 
raised. 

5.  Circumduction  of  wrist  for  stretching.  —  Strap  the  wrist 
and  forearm,  grasp  the  handle,  and  turn  the  wheel  about 
twenty  revolutions  each  way.  Move  out  the  attachment 
to  the  farthest  possible  point  compatible  with  the  movement. 


Fig.  58.  —  Circumduction  of  wrist. 


The  operator  may  assist  at  the  most  difficult  part  of  the  turn, 
by  turning  the  crank. 

6.  Ad-  and  abduction  of  wrist.  —  Place  the  fingers  under 
the  straps  on  the  hand  board,  strap  down  the  wrist  and  fore- 
arm, ad-  and  abduct  the  hand,  noting  the  range  of  movement 
on  the  protractor.  The  weights  will  vary  for  these  two  move- 
ments, which  should  be  done  separately. 

7.  Flexion  and  extension  of  wrist.  —  (i)  Grasp  the  roller 
overhand  and  wind  up  the  weight,  without  releasing  the 
grasp  and  exerting  the  full  range  of  movement.  The  scale 
will  measure  the  range  of  the  joint,  and  the  weight  and 
distance  multiplied  gives  the  total  work  done  in  foot 
pounds. 


RECLAIMING    THE   MAIMED  75 

Precaution:   see  that  the  movement  is  done  at  the  wrist 
only  and  not  at  the  elbow  or  shoulder. 

(2)  Reverse  the  grasp  and  repeat  for  flexion. 


Fig.  59-  —  Adduction  and  abduction  of  wrist.     Note  the  scale  to  measure  the 

angle  of  movement. 

8.  Pronation  and  supination.  —  Patient  stands  facing  the 
machine  and  grasps  the  handle  with  the  left  hand,  his  left 
elbow  joint  flexed,  his  right  forearm  across  his  back,  and  his 
hand  grasping  his  left  arm  above  the  elbow  to  prevent 
sideways  movement.     Set  weight  and  ratchet  for  supination 


76 


RECLAIMING   THE   MAIMED 


RECLAIMING    THE   MAIMED  77 

and  turn,  counting  the  clicks  for  each  movement  and  noting 
the  weight  and  the  distance  raised.  The  measurement  of  each 
movement  will  appear  on  the  protractor.  See  that  patient 
does  not  move  his  elbow  out  or  in,  or  twist  body.  Reverse 
the  ratchet  and  repeat  for  pronation. 

9.  Flexion  and  extension  at  elbow.  —  (i)  The  patient  faces 
the  triplicate  machine,  grasping  the  floor  handle,  the  arm 
and  cord   in  line.     Flex 

and  relax  the  forearm.  *      ^ f\ 

(2)  Patient  faces  away  •*'       />^  ^/ 

from  the  machine,  grasp-  .  •*'        /J  .  'v 

ing  the  shoulder  handle,        /  //  *     ^ 

the  arm  full  flexed,  the    •*  ^(  3«  •'C   .'C 

upper  arm  in  line  with  Fig.  61  Fig.  62. 

the   cord.      Extend   and 

relax  the  forearm.  In  both  these  exercises,  the  position  of 
the  upper  arm  must  remain  unchanged.  If  this  is  not  done, 
the  direction  of  the  pull  is  changed. 

10.  Shoulder  rotation.  —  Grasp  the  floor  handle,  the  elbow 
on  a  bracket,  shoulder  high,  the  forearm  flexed  to  a  right 

\ 

n>         <r/\  <'/\ 

Fig.  63  Fig.  64.  '  Fig.  65. 

angle.  Pull  up  with  the  hand,  throughout  whole  range  of 
shoulder  movement  without  changing  the  height  of  the  elbow 
or  its  angle  of  flexion. 

11.  Flexion  and  extension  0}  shoulder  joint.  —  (i)  The 
patient  stands  with  his  back  to  the  floor  handle,  the  arm 
down  and  straight.  Arm  forward,  raise,  and  lower.  (2)  Face 
to  the  floor  handle,  draw  the  arm  back,  and  lower  to  position. 


78 


RECLAIMING   THE  MAIMED 


12.  Ad-  and  abduction  of  the  shoulder.  —The  patient 
stands  with  the  side  to  the  tripHcate  machine,  shoulder  at- 
tachment, arm  and  cord  in  hne.  (i)  Bring  the  arm  forward 
across  the  chest.     (2)  Patient  stands  as  in  exercise  i,  but 


J 


Fig.  66 


Fig.  67. 


> — .0 

Fig.  68. 


o 


V; 

Fig.  69. 


using  the  floor  attachment.  Bring  the  straight  arm  upward, 
and  lower  to  position.  (3)  Patient  stands  with  his  side  to 
the  machine,  overhead  attachment,  arm  in  Une  with  the  cord. 
Bring  the  arm  downward  and  forward,  then  downward  and 
backward,  alternately.     (4)  The   patient  stands   with    the 

side  from  the  machine, 
the  arm  across  chest, 
grasping  the  shoulder 
attachment.  Extend 
the  forearm  and  arm, 
keeping  them  at  the 
shoulder  level. 

13.  Passive  abduction 
of  shoulder.  —  Patient 
standing  with  the  side 
to  the  creeping  board, 
and  the  forearm  rigidly  extended.  Climb  up  the  board  by 
the  fingers  with  a  straight  arm,  and  note :  ist,  the  highest 
point  at  which  the  Angers  can  be  lifted  from  the  board 
by  the  patient ;  2d,  the  level  to  which  he  can  bring  up  his 
arm,  without  bending  his  elbow.  Fig  72.  Keep  the  body 
rigid  throughout,  not  bent  or  twisted. 


Fig.  70. 


Fig.  71. 


I 

0/: 

Fig.  72. 


RECLAIMING   THE   MAIMED 


79 


Fig.  7,3.  —  Crumpling  up  a  newspaper  as  an  exercise  for  the  hand. 


80 


RECLAIMING    THE   MAIMED 


RECLAIMING    THE   MAIMED 


81 


General  movements  that  are  of  value  in  treating  the 
muscles  of  the  upper  extremity  are  rolling  up  a  ball  of  paper, 
throwing  and  catching  balls  of  all  sizes  and  weights,  quoits, 
bowling,  pingpong,  crokinole,  billiards,  weaving,  knitting, 
rope  splicing,  knots,  the  use  of  tools,  like  scissors,  boring. 


Fig.  75.  —  The  inversion  and  eversion  treads  in  use.     Hart  House. 


hammering,  modeling,  painting,  bookbinding,  saddlery,  and 
shoemaking. 

Lower  Extremity.  —  14.  Circumduction  0}  the  ankle.  — 
The  patient  sits  with  his  foot  strapped  in  place.  The  range 
of  movement  is  regulated  by  a  thumb  screw  on  the  crank. 
The  handle  is  turned  by  the  patient  or  operator,  for  this 
stretching  movement,  which  should  precede  the  voluntary 
active  movements  of  the  ankle. 


82  RECLAIMING   THE  MAIMED 

15.  Inversion  and  Eversion  of  Foot.  —  (i)  The  patient 
walks  on  the  inversion  ridge,  Fig.  75,  a  definite  distance,  with 
hand  rail  support. 

(2)  Ditto  for  eversion.  Both  (i)  and  (2)  are  stretching 
movements,  and  should  precede  (16). 

(16)  The  patient  is  seated  with  the  foot  and  leg  strapped  to 
the  apparatus,  Fig.  76.  Evert  the  foot  against  the  weight  on 
the  cord,  and  note  the  range  of  the  movement  on  the  pro- 
tractor, and  the  total  weight  raised.  Reverse  this  ratchet  and 
repeat  for  inversion. 

16.  Dorsiflexion  of  ankle.  —  The  patient  sits  or  stands  with 
his  foot  strapped  to  the  footpiece.  Fig.  77.  Flex  the  ankle, 
raising  the  weight.  The  extent  of  the  movement  may  be 
estimated  by  the  number  of  clicks,  the  exact  measurement 
noted  on  the  protractor,  and  the  total  work  done  is  easily 
calculated. 

17.  Rotation  of  the  knee.  —  (a)  The  patient  is  seated  with 
the  foot  strapped  to  the  footpiece,  and  the  leg  against  the 
brace,  Fig.  78.  He  ad-  or  abducts  the  foot,  rotating  the 
knee,  the  extent  of  each  movement  being  marked  on  the 
protractor,  (b)  The  patient  stands  with  the  knee  locked  in 
extension  as  ad-  or  abduct  the  foot.  Fig.  79.  This  move- 
ment measures  hip  rotation,  if  care  be  taken  to  keep  the 
pelvis  fixed.  In  either  position,  the  movement  of  the  flexed 
ankle  is  slight. 

18.  Knee  flexion  and  extension. — Triplicate  machine. 
Exercise  i.  Face  to  the  machine,  strap  the  foot  to  the  floor 
attachment.     Movement :    Flex  the  knee  against  resistance. 

Exercise  2.  Face  from  the  machine,  strap  the  foot  to  the 
floor  attachment,  the  flexed  leg  and  cord  in  the  same  line. 
Movement :  Extend  the  knee  against  resistance. 

19.  Hip  ad-  and  abduction.  —  Triplicate  machine.  Exer- 
cise I.  Side  to  the  machine,  the  foot  strapped  to  the  floor 
attachment.  Movement:  Adduct  the  thigh,  keeping  the 
knee  straight. 


RECLAIMING    THE   MAIMED 


83 


f'iG.  76.  —  Eversion  and  inversion  of  ankle.  Note  the 
fixation  of  the  leg,  also  the  scale  and  pointer  marking 
the  angle  of  movement. 


84 


RECLAIMING    THE  MAIMED 


Fig.  77.  —  Exercise  for  foot  drop.   Note  scale  and  pointer  to  record 
angle  of  movements  on  left  side,  and  fixation  of  leg  near  the  knee. 


RECLAIMING    THE   MAIMED 


85 


86 


RECLAIMING    THE   MAIMED 


Fig.  79.  —  Rotation  of  hip  —  the  knee  extended  and  the 
pelvis  fixed. 


RECLAIMING   THE   MAIMED  87 

Exercise  2.  Side  from  the  machine,  foot  strapped  to  the 
floor  attachment.  Movement :  Abduct  the  thigh,  keeping 
the  knee  straight. 

20.  Hip  flexion  and  extension.  —  Exercise  i.  Face  to  the 
machine,  foot  strapped  to  the  floor  attachment.  Move- 
ment :    Extend  the  thigh  with  the  leg  stretched. 

^L  .ir^        .j-'^>^ 

Fig.  80.  Fig.  81.  Fig.  82.  > 

Exercise  2.  Face  from  the  machine,  foot  strapped  to  the 
floor  attachment.  Movement :  Flex  the  thigh,  keeping 
the  knee  straight. 

21.  Thigh  flexion,  knee  flexion,  foot  dorsiflexion. — Patient 
steps  through  the  rungs  of  a  horizontal  ladder  with  par- 
allel  bar   arm   rests.      The  ladder  is  made  adjustable  for 

0  Q  ^ 

<R  ^         ^|\ 

-jC-^-  d-->  -iv-^- 

Fig.  83.  Fig.  84.  Fig.  85. 

height  at  one  end,  and  raised,  to  increase  the  movement  re- 
quired to  raise  the  foot  over  each  rung.  This  is  especially 
useful  for  leg  amputation  cases.  Fig.  86. 

22.  (9)  Thigh  extension,  knee  extension,  foot  planta- 
flexion.  —  The  bicycle  trainer  with  an  increasing  load  of 
distance  or  friction. 

General  exercises  :  walking,  hill  climbing,  dancing,  kicking 
a  football  or  hockey  puck,  balancing,  skipping. 


RECLAIMING    THE   MAIMED 


RECLAIMING    THE   MAIMED 


89 


In  the  treatment  of  stumps,  a  sheath  should  be  attached 
and  the  various  pulley  weight  movements  carried  out  as 
if  the  limb  were  intact. 

Amputations.  —  The  reeducation  of  amputation  cases 
begins  with  the  preparation  of  the  stump,  and  fitting  of  the 


Fig.  87.  —  The  bicycle  is  arranged  with  adjustable  pedals  and  resistance. 
It  can  also  have  motor  for  passive  movement.     Hart  House. 

artificial  limb  for  comfort,  and  for  the  correct  bearing  of 
the  w^eight.  The  patient  should  first  learn  to  balance, 
which  may  be  made  safe  if  he  be  suspended  by  a  belt  under 


90 


RECLAIMING   THE  MAIMED 


the  arms,  working  from  an  overhead  trolley  or  by  grasping 
a  bar.  This  inspires  confidence,  and  prevents  falls,  espe- 
cially in  amputation  at  the  thigh,  where  the  balance  is  very 
difiicult  to  get.     The  patient  then  progresses  to  the  use  of 


Fig.  88.  —  Amputated  case  learning  control  on  the  balance  beam. 


Sticks  and  progression  on  a  smooth  surface.  He  should  dis- 
card crutches  from  the  first.  This  is  very  important.  He 
then  learns  to  walk  on  a  smooth,  level  surface  with  one  stick 
only,  to  clear  obstacles,  like  the  ladder  rungs  already  de- 


RECLAIMING    THE   MAIMED  91 

scribed,  and  finally  to  walk  through  soft  sand  on  uneven 
ground,  up  and  down  inclines,  and  over  obstructions. 

Lynn  Thomas  worked  out  an  excellent  plan  at  the  Prince 
of  Wales  Hospital,  for  limbless  men,  at  Cardiff,  where,  with 
the  help  of  a  landscape  gardener,  he  constructed  a  sort  of 
golf  course,  with  suitable  bunkers  to  illustrate  the  diffi- 
culties a  limbless  man  would  have  to  overcome.  In  the 
grounds,  the  walks  were  graded  in  slopes  from  one  to  twelve 
up  to  one  in  three,  mounds  of  earth  covered  with  shrubs 
were  constructed,  an  artificial  pond  with  a  bridge  to  be 
crossed,  a  stile  and  gate,  paths,  built  on  a  slant,  tilted  to  right 
and  to  left.  All  such  devices  add  interest  to  the  process 
of  perfecting  the  patients  in  the  use  of  their  artificial  limbs, 
and  supplement,  and  gradually  replace,  the  more  simple 
developmental  work  of  the  treatment  room. 


CHAPTER  VIII 
GYMNASTICS   AND    GAMES 

The  object  of  gymnastics  is  to  reeducate  control,  alert- 
ness, accuracy,  speed,  and  strength  in  men  who  have  lost 
them  through  neglect,  injury,  or  the  enforced  idleness  of 
hospital  life. 

The  whole  tendency  of  daily  life  in  the  hospital  is  to  make 
men  sluggish  in  mind  and  body.  Discipline  is  relaxed,  and 
their  stamina,  physical,  mental,  and  moral,  suffers  in  con- 
sequence. In  a  table  of  gymnastic  exercises,  the  enforced 
discipline  is  not  the  least  important  part  of  the  treatment  in 
refitting  them  to  take  their  place,  either  in  military  or  civil 
life. 

Gymnastic  exercise  should  be  considered  as  a  part  of  the 
treatment,  and  should  count  as  a  parade.  Patients  should 
be  classified  according  to  their  physical  condition  and  require- 
ments, and  this  classification  given  to  the  instructor. 

Class  I.  Fit  for  duty.  Able  to  take  gymnastic  tables  i 
and  2,  for  convalescents,  gymnastic  games  and  marching, 
running,  jumping,  manual  and  vocational  work. 

Class  II.  Fit  for  light  duty.  Able  to  take  gymnastic 
tables  I  and  2  for  convalescents,  walking,  light  games,  no 
running  or  jumping,  light  vocational  work. 

Class  III.  Unfit  for  duty.  Under  individual  treatment 
and  unfit  for  class  work  or  games.  Each  case  to  be  judged  on 
its  merits. 

92 


RECLAIMING    THE   MAIMED 


93 


Men  who  have  lost  an  arm  or  hand,  or  who  have  a  stiff 
knee  or  ankle,  may  be  put  in  class  II  and  go  through  such 
exercises  as  are  within  their  power,  standing  fast  when  they 
come  to  an  exercise  beyond  their  power,  and  going  on  when 
the  next  movement  is  given.  This  is  much  better  than  ex- 
cusing them,  or  putting  them  in  classes  by  themselves,  and 


Fig.  89.  —  Slow  balance  exercise.     Knee  raising.     Heaton  Park. 
Note  that  three  men  are  standing  fast. 


there  should  be  constant  and  repeated  inspections  by  the 
medical  officer  to  see  that  no  injury  is  done,  and  also  that  all 
exercises  within  their  power  are  done. 

Between  five  and  ten  per  cent  of  hospital  cases  have  some 
irregularity  of  heart  action,  and  the  treatment  by  electricity 
and  water  must  be  accompanied  and  gradually  replaced  by 
progressive  exercise.    These  irritable  hearts  are  frequently 


94  RECLAIMING   THE  MAIMED 

but  symptoms  of  general  nervous  disturbance  or  exhaustion. 
For  them,  exercise  must  begin  with  caution,  and  the  load  be 
increased  with  care.  A  rise  in  the  pulse  rate,  persisting 
twenty-four  hours,  is  the  signal  of  overwork.  At  Heaton 
Park  we  found  the  greatest  benefit  from  faradism,  long-con- 
tinued sedative  baths  every  second  day,  followed  by  rest. 
On  alternate  days,  these  patients  had  gymnastic  exercises  as 
in  tables  i  and  2,  and  slow  walking  of  one  half  to  one  mile. 
As  the  need  for  men  in  the  firing  line  was  urgent  at  that  time, 
they  were  then  tried  on  a  table  of  exercises,  including  running 
and  jumping,  and  were  also  tested  on  a  four-mile  march. 
About  thirty  per  cent,  only,  were  able  to  stand  it,  and  were 
passed  as  fit.  The  others  showed  a  return  of  symptoms  that 
remained  latent  under  the  lighter  forms  of  exercise. 

At  the  Hampstead  Military  Hospital  for  the  heart,  where 
only  difScult  cases  were  sent,  about  fourteen  per  cent  were 
returned  to  the  firing  line,  but  nearly  fifty  per  cent  were  made 
fit  for  some  form  of  military  work.  Graduated  exercises  have 
shown  at  both  places,  not  only  that  they  cause  improvement, 
but  that  they  form  admirable  tests  for  estimating  fitness  for 
duty.  It  is  often  possible  to  state,  after  physical  examination 
alone,  that  a  man  is  unfit  for  duty,  permanently,  but  it  is 
never  possible  to  decide,  after  physical  examination  alone, 
that  a  patient  will  be  fit.  The  reaction  to  exercise  forms  the 
deciding  test. 

In  sanataria  for  tuberculosis,  a  patient  in  whom  the  tem- 
perature has  become  normal  is  prepared  for  work  by  light 
exercise,  principally  walking,  and,  as  soon  as  he  has  reached 
the  stage  when  a  half  hour's  walk  twice  a  day  causes  no  signs 
of  relapse,  he  is  allowed  to  take  up  the  lighter  forms  of  voca- 
tional training.  In  many  men,  suffering  from  the  effects  of 
irritating  gas,  the  bronchitis  and  functional  spasm,  asth- 
matic in  character,  can  be  greatly  benefited  by  slow,  controlled 
breathing  exercises. 

Among  the  cases  suffering  from  shell  shock,  exercises  of 


RECLAIMING    THE   MAIMED 


95 


equilibrium  present  peculiar  difficulties,  and  concentration, 
confidence,  and  courage  can  be  well  cultivated  by  the  balance 
beam. 

The  period  of  debility  following  typhoid,  dysentery,  or 
other  exhausting  diseases  will  be  greatly  shortened  by  start- 
ing them  early  on  progressive  gymnastic  exercise,  sufficiently 


Fig.  go.  —  Slow  deep  breathing  exercises.     Heaton  Park. 


vigorous  to  tone  up  the  flabby  muscles,  without  causing  too 
great  exhaustion. 

The  following  two  tables  are  compiled  for  use  in  hospitals 
and  convalescent  camps,  the  exercises  being  selected  from 
the  Aldershot  tables  for  recruits.  They  cover,  in  a  system- 
atic way,  the  various  regions  of  the  body,  with  the  thorough- 
ness that  characterizes  the  Swedish  system,  but  quick  and 
jerky   movements,   likely   to   strain   an   injured   joint,   are 


96 


RECLAIMING   THE  MAIMED 


avoided.  The  progression  is  from  partial  to  complete  move- 
ments of  the  joints,  e.g.  from  knee  bending  to  full  knee  bend- 
ing, and  they  contain  no  jumping  or  running  exercise.  In 
all  cases  of  class  I,  and  most  cases  of  class  II,  they  can  be 
done  in  addition  to  treatment  and  vocational  training,  for 
their  object  is  not  only  medical,  but  disciplinary,  and  it  is  of 


Fig.  91.  —  Balance  exercises  on  the  elevated  beam.     Heaton  Park. 


the  utmost  importance  for  the  instructor  to  insist  on  exact- 
ing smartness  and  discipline.  The  time  occupied  should  not 
exceed  thirty  minutes,  as  the  attention  of  these  patients  soon 
tires,  and,  in  many  cases,  the  time  should  be  considerably 
reduced.  They  should  be  done  daily,  the  first  table  for  two 
weeks,  and  the  second  for  two  weeks  more.  In  the  second 
table,  quickening  exercises  and  running  games  can  be  in- 
creasingly used,  in  preparation  for  the  free  games  and  occu- 
pations into  which  the  patient  is  gradually  initiated. 


RECLAIMING   THE  MAIMED 


97 


Table  I.     {A)  Introductory  Exercises 


Leg  exercise. 
Neck  exercise. 
Arm  exercise. 

Trunk  exercise. 
Leg  exercise. 


{a)  Feet  close ;  (h)  heels  raise. 

Head  backward  bend. 

{a)     Hips     firm ;     {b)      arms     bend ; 

(c)  arms  bend,  arms  upward  stretch. 
Feet  close,  hips  firm,  trunk  turning, 
(a)  Hips   firm,    foot   sideways   place ; 

{b)  feet  astride  place. 


{B)  General  Exercises 

Preparation  for  span     Feet    astride,    arms    upward  stretch 

bending.  (taken  free). 

Balancing  exercise.       Hips  firm,  knee  raise. 
Lateral  exercise.  Feet  close,  hips  firm,   trunk  bending 

sideways. 
Abdominal  exercise.     Hips  firm,  foot  sideways  place,  trunk 

bending  forwards. 
Marching  exercise.       Quick    march ;      (later)    on    the    toes 

march. 
"Practice  class  arrangements  ;    in  two  ranks  fall  in,  number- 
ing, opening,  and  closing  ranks. 


(C)  Final  Exercises 

Heels  raise.     Arms  raising  sideways. 

The  movements  in  this  table  should  be  done  slowly  and 
evenly.  The  instructor  should  avoid  taking  up  much  time 
with  individual  correction. 

Emphasis  should  be  placed  on  exactness  and  accuracy  of 
movement  and  on  mental  alertness  and  promptness  of  re- 
sponse to  command. 

H 


98 


RECLAIMING    THE  MAIMED 


Table  II. 
Leg  exercise. 


Neck  exercise. 


Arm  exercise. 


Trunk  exercise. 


Leg  exercise. 


{A)  Introductory  Exercises 

Hips   firm,    heels   raising   and   knees 

bending  (latter  quickly). 
Head  bending  backward   (later  head 

turning) . 
{a)  Arms  bend,  one  arm  upward,  one 

arm   downward  stretch;     {h)  arms 

bend,  arms  sideways  stretch. 
Hips  firm,  foot  sideways  place,  trunk 

turning. 
{a)  Feet  close  and  full  open ;  {h)  hips 

firm,  foot  placing  sideways. 


{B)  General  Exercises 


Preparation  for  span 
bending. 

Balancing  exercise. 

Lateral  exercise. 


Abdominal  exercise. 

Dorsal  exercise. 
Marching  exercise. 


Feet  astride,  arms  upward  stretch, 
trunk  backward  bend  (slight  move- 
ment only). 

Hips  firm,  leg  raising  sideways  ;  (later) 
backward  and  forward. 

Hips  firm,  foot  sideways  place,  trunk 
bending  sideways  ;  (later)  feet  close, 
one  arm  upward  and  one  arm  down- 
ward, trunk  bending  sideways. 

{a)  On  the  hands  down  (by  numbers) ; 
{h)  on  the  back  down  (ground  permit- 
ting) ;   (later)  with  the  leg  raising. 

Hips  firm,  foot  sideways  place,  trunk 
forward  bend,  trunk  downward  bend. 

Hips  firm,  with  knee  raising  quick 
mark  time. 


(C)  Final  Exercises 

Hips   firm,   foot   sideways   place,   trunk   turning.     Heels 
raise.    Arms  raising  sideways  and  upwards. 


RECLAIMING    THE   MAIMED 


99 


Patients  unable  to  perform  single  movements  should 
stand  at  ease. 

The  time  taken  by  these  tables  should  not  occupy  more 
than  half  of  the  hour  set  apart  for  exercise.  The  second  half 
should  be  taken  up  with  games  and  recreation,  in  which 


Fig.  92.  —  High  knee  raising  through  wire  entanglements  at  the  double. 

Heaton  Park. 


discipline  does  not  play  a  prominent  part.  These  should 
consist  of:  i.  Dancing  steps  forward,  backward,  and  to  the 
sides,  first  taken  to  count,  and  then  to  music,  and  combined 
into  series  or  dances.  2.  Tag  garner,  like  three-deep,  hunt  the 
slipper,  dodge  ball.  3.  Relay  races,  medicine  ball  passing, 
and  message  relays,  and  games  for  general  development,  such 
as  golf,  tennis,  handball,  basket  ball,  cricket,  baseball,  and 
swimming,  for  which*  may  be  substituted,  in  special  cases, 
sports  for  development  of  the  upper  extremity,  like  billiards, 
bowling,  quoits,  or  sports  for  developing  lower  extremities, 
like  walking,  dancing,  soccer,  and  cycling. 


100  RECLAIMING   THE  MAIMED 

The  following  series  shows  a  progression  suitable  for  men 
who  have  to  begin  with  the  simplest  movements,  and  feel 
their  way  to  more  difhcult  and  complicated  combinations. 
The  instructor  should  always  be  on  the  watch  to  prevent  men 
from  undertaking  movements  which  their  disability  might 
make  dangerous. 

I.   Jumping  and  Dancing 

Jumping  the  rope.  Men  in  file.  Two  men  take  the  ends 
of  a  rope  eight  feet  long,  and  walk  back,  one  on  either  side 
of  the  file,  dragging  it,  the  men  jumping  the  rope  as  it  passes. 
Repeat  at  the  double. 

Jumping  the  swinging  rope.  Men  in  a  circle.  The  in- 
structor, in  the  center,  swings  a  shot  bag,  attached  to  a  rope, 
the  men  jumping  it,  as  it  is  let  out,  and  the  speed  increased. 

Dancing  steps. 

/?>         ^F>s  y?x  ?\^        '•   ^^^^'    together. 

*J^  \\/  (1/  v//    Jump    and    point    to 

I  /  \  \  W  /  /      left.     Jump  and  point 

tL  1    ">  II  ^^   L     to  the  right. 

"""^  "^'V         ""  ''^  2.   Heels    together. 

■  ^'^"  Jump    and    point    to 

the  left,  turning  the  heel  out.     Jump  and  touch  left  heel. 

Jump  and  point  to  the  right,  heel  out.     Jump  and  touch 

right  heel. 
0  ^  p  C^        3.    Heels    together. 

(I)  ^^  ^w  O     J^^P  ^^^  toMoh  left 

li  y/  i\  y-i      heel.    Jump  and  bring 

j'  'V  V  I  mJ  I        l^^t  foot  across  right, 

-••L  w'.  7*        «••••'  k.  .'-^      pointing  and  touching 

Fig.  94.  the   toe.     Jump    and 

kick  to  the  left. 
This  is  a  simple  series  and  excellent  for  balance,  coordina- 
tion, and  rhythm.     They  should  be  done  slowly  at  first,  to 
command,  and  then  to  music. 


RECLAIMING    THE   MAIMED  101 

Tag  games. 

These  should  be  made  progressive,  beginning  with  squat 
tag,  in  which  the  player  saves  himself  from  being  tagged  by 
squatting  in    the  full         ^ 

knee    bend    position.       >  jv       ^fV  yf^       ^>. 

This  may  be  varied  by     (  |  /       \  \  >  \  \  >      Qj 

having  him  take  the       \/  \\  \\  \  ^%^  ^ 

arms   upward   stretch        ||  I    \-^       */\  l        ' 

position,  and  so  secure      *''*'*•        "^ '  '  .        *^'  ' 

a  gymnastic  effect,  in  ^^'  ^^' 

addition.     In  cap  tag,  a  cap  or  ball  is  passed  from  man  to 
man,  and  the  man  who  is  "it"  tries  to  tag  the  holder. 

A  simple  and  popular  game  is  the  Bogey  Man.  In  this, 
a  player,  chosen  as  the  Bogey  Man,  stands  at  one  end  of  the 
yard,  the  other  players  stand  at  the  opposite  end.  At  a 
signal  from  him,  they  run,  trying  to  pass  him  and  reach  the 
opposite  end  of  the  yard.  He  tags  one  or  two,  and  they 
go  with  him  to  his  side  of  the  yard,  and  help  him.  The 
play  is  repeated  until  all  the  runners  are  caught  by  the 
Bogey  Man  and  his  helpers.  The  last  one  caught  begins  a 
new  game. 

A  more  highly  organized  form  of  this  game  is  Prisoner's 
Base.  In  this,  the  play  field  is  about  thirty  by  seventy-five 
feet.  A  line  across  the  field  at  each  end  marks  the  base  of 
each  team.  At  the  right  of  each  base  a  small  space  is  marked 
off  as  a  prison.  The  teams  each  consist  of  about  ten  players. 
The  object  of  the  game  is  to  make  prisoners  of  the  players  on 
the  opposite  team.  Any  player  may  be  made  a  prisoner  by 
an  opposing  player  who  left  his  base  later  than  the  first  player 
did.  For  instance,  a  player  of  Team  No.  i  leaves  his  base, 
and  advances  toward  the  base  of  Team  No.  2.  Having  left 
his  base,  he  may  be  tagged  by  any  player  on  Team  No.  2. 
When,  therefore,  an  opposing  player  runs  out  to  tag  him,  he 
quickly  retreats  to  his  own  base  before  being  tagged.  If  he  is 
tagged  before  reaching  his  base,  he  is  a  prisoner,  and  is  put 


102  RECLAIMING   THE  MAIMED 

into  the  prison  of  Team  No.  2.  If,  however,  a  player  of  his 
own  team  runs  out  to  support  him,  and  this  new  player  (who 
left  his  base  later  than  the  pursuer)  succeeds  in  tagging  the 
player  from  Team  No.  2,  then  this  one  is  a  prisoner,  and  is 
placed  in  the  prison  of  Team  No.  i. 

When  a  prisoner  is  made,  the  captain  of  the  team  designates 
a  player  whose  duty  it  is  to  guard  the  prison.  The  capture 
of  three  prisoners  by  one  team  wins  the  game.  Prisoners 
may  be  freed  when  one  of  the  players  succeeds  in  tagging  a 
prisoner  without  himself  being  tagged.  If  there  are  two 
prisoners,  they  may  grasp  hands  and  stretch  out  toward  their 
team,  thereby  facilitating  their  release.  If,  then,  the  first  one 
is  tagged,  they  are  both  free. 

Two  circle  games  may  be  mentioned :  The  Beetle  Is  Out, 
and  Dodge  Ball. 

In  The  Beetle  Is  Out,  the  players  form  a  closed  circle, 
shoulder  to  shoulder,  facing  inward,  and  having  their  hands, 
with  palms  open,  behind  their  backs.  One  of  the  players  is 
outside  the  circle.  He  carries  a  handkerchief  with  a  knot 
tied  in  one  end  of  it  or  a  stuffed  bag.  Running  around  the 
outside  of  the  circle,  he  puts  the  handkerchief  into  the  hand 
of  one  of  the  players,  if  possible,  without  being  noticed  by 
the  others.  When  the  leader  calls,  "The  beetle  is  out,"  the 
one  having  the  handkerchief  turns  and  strikes  his  right-hand 
neighbor  on  the  back  with  the  knot,  the  neighbor  seeking  to 
avoid  the  blows  by  running  around  the  circle,  until  he  regains 
his  former  place.  The  pursuer  now  starts  around  the  circle, 
placing  the  handkerchief  in  another  man's  hand,  and  the 
game  continues  as  before. 

In  Dodge  Ball  the  men  are  divided  into  teams.  Team  A 
stands  inside  a  circle  forty-five  feet  in  diameter,  while  Team  B 
stands  outside  the  circle,  and  attempts  to  throw  a  basket  ball 
so  as  to  strike  one  of  the  members  of  Team  A.  If  any  player 
of  Team  A  is  touched  by  the  ball  on  the  fly  or  bounce,  a  point 
is  scored  for  the  outer  team.     If  a  player  is  struck,  he  remains 


RECLAIMING    THE   MAIMED  103 

in  the  game,  and  the  game  continues  without  interruption  for 
three  minutes,  when  the  positions  are  reversed,  and  Team  A 
throws  the  ball  at  Team  B ,  and  the  team  securing  the  greatest 
number  of  points  during  the  game  shall  be  the  winner. 

There  are  an  infinite  number  of  relay  races,  beginning  with 
passing  a  medicine  or  basket  ball,  the  players  remaining  in 
place,  and  going  on  to  running  and  carrying  relays.  The 
following  is  a  simple  progression. 

1.  Men  in  file.  The  ball  is  passed  back  between  the  legs. 
The  last  man  carries  it  forward  and  repeats.  This  is  done 
by  lines  in  competition. 

2.  Men  in  file.  The  ball  is  passed  back  over  the  head,  and 
the  last  man  carries  it  forward  as  before. 

3.  Men  in  file,  all  but  three,  A,  B,  and  C,  who  are  facing 
the  file  five  yards  away.  At  the  signal,  the  first  man  runs 
with  the  ball,  circles  A,  and  gives  him  the  ball.     A  circles  B, 


Fig.  96. 


and  gives  him  the  ball.  B  circles  C,  and  gives  him  the  ball. 
He  runs  back  to  No.  2,  circles  him,  and  gives  him  the  ball, 
and  then  takes  his  place  in  the  rear. 

4.  Men  in  file  except  A,  who  is  five  yards  in  front  of  No. 
I.  A  message  is  given  confidentially  to  A  in  each  file.  A 
runs  to  No.  i  and  brings  him  back,  repeating  the  message 
on  the  run.  No.  i  runs  to  No.  2,  repeating  the  message  as 
they  run,  and  so  on  till  the  whole  file  is  transferred  to  the 
other  side. 


^*v ..^ > y    ^y     ^/ 


t 


Fig.  97, 


104  RECLAIMING    THE   MAIMED 

In  addition  to  these  difficult  relays,  are  shuttle  relays, 
potato  races,  and  other  varieties,  described  in  reference  books. 

The  medicine  ball  is  the  most  useful  single  piece  of  ap- 
paratus.    It  should  be  at  least  twelve  inches  in  diameter,  and 


?   f  4   -P 


17      yi       \\       /\       -!"=?. 


9 


Fig. 


may  be  stuffed  with  anything  to  bring  the  weight  up  to  ten 
pounds  or  over.  Passing  relays  can  be  arranged,  illustrating 
the  different  methods  of  throwing  and  catching  the  medicine 
ball,  in  a  circle,  in  lines,  or  individually. 


CHAPTER    IX 
TREATMENT   BY   OCCUPATION 

Treatment  by  occupation  differs  from  all  other  forms 
already  described,  in  that  the  remedy  is  given  in  increasing 
doses  with  its  patient's  improvement.  It  is  the  final  stage 
in  his  progress,  to  which  all  the  others  lead  up. 

In  England  and  France,  where  great  numbers  of  wounded 
were  thrown  on  the  community  at  once,  the  country  houses, 
given  by  the  public-spirited  owners  as  auxiliary  Red  Cross 
Hospitals,  too  often  became  nurseries  of  the  "hospital  habit." 
Men  who  came  to  them  keen,  well-disciplined,  and  alert, 
too  often  lapsed  in  an  atmosphere  of  indulgence  and  hero 
worship  into  disorderly  loafers,  seeking  a  grievance  in  every 
regulation  made  for  their  control.  Their  natural  hunger  for 
movement  became  lost  in  a  progressive  lethargy  of  mind 
and  body.  To  combat  this  growing  evil  the  Surgeon  Gen- 
eral, Sir  Alfred  Keogh  established  Command  Depots,  where 
men  were  again  put  under  strict  discipline,  but  in  which 
treatment  by  physical  therapy  took  the  place  of  regular 
military  training.  A  beginning  was  made  by  establishing 
workshops  in  them,  at  Tipperary,  under  Lieutenant-Colonel 
Sims  Woodhead,  R.A.M.C.,  to  give  both  treatment  and  oc- 
cupation, and  this  plan  was  soon  extended  to  others.  In 
the  orthopedic  centers,  convalescent  camps,  and  many 
hospitals,  notably  at  Roehampton,  Netley,  and  Brighton, 
they  are  increasingly  used  as  part  of  the  treatment ;  and  the 
Military  Hospitals  Commissioners  made  occupational  ther- 

105 


106  RECLAIMING   THE  MAIMED 

apy  and  vocational  training  an  integral  part  of  the  scheme 
of  treatment  in  their  chain  of  hospitals  across  Canada. 

A  distinction  is  frequently  drawn  between  occupational 
therapy  and  vocational  training.  In  the  former,  the  move- 
ments are  given  as  treatment,  and  the  work  done  is  a  sec- 
ondary consideration.  The  patient  saws  wood  because  the 
arm  muscles  can  thus  be  contracted  and  relaxed  a  definite 
number  of  times.  It  is  really  a  gymnastic  exercise  done 
with  a  saw. 

In  vocational  training  the  object  is  to  make  a  good  box 
by  sawing  the  board  in  definite  lengths,  and  the  arm  exercise 
is  secondary,  though  essential.  It  is  a  question  of  emphasis, 
and  it  is  impossible  to  draw  a  sharp  line  of  distinction  in 
most  cases.  Wherever  the  emphasis  is  laid,  every  man  is 
benefited  by  occupation  that  keeps  both  his  mind  and  body 
busy. 

Hospital  life  gives  plenty  of  time  for  introspection  and 
consequent  depression,  and  to  many  a  returned  soldier  this 
acts  as  a  poison,  counteracting  all  attempts  to  bring  him  back 
to  normal  mental  and  physical  condition.  He  becomes 
discouraged,  and,  worst  of  all,  he  becomes  content  to  sit 
with  folded  hands,  bereft  of  ambition  or  purpose  in  life. 

The  purpose  of  occupational  therapy  is  threefold : 

1 .  Physical :  To  carry  on  the  improvement  in  muscular 
strength  and  control,  obtained  by  treatment,  and  to  apply 
it  to  the  varied  movements  that  the  carpenter  uses  in  han- 
dling his  tools  or  the  gardener  in  cultivating  his  land. 

2.  Vocational :  To  give  him  an  education  directed  to 
make  him  able  to  keep  a  set  of  books,  or  take  a  position  in 
business  where  the  handicap  of  a  missing  leg  or  an  impaired 
arm  will  not  be  felt. 

3.  Moral,  or  self-disciplinary:  To  give  courage  to  begin 
life  over  again,  sometimes  in  a  new  trade  or  business.  To 
give  him  that  self-respect  that  makes  him  want  to  stand  on 
his  own  feet,  and  not  be  dependent  on  charity  or  the  efforts 


RECLAIMING   THE  MAIMED 


107 


of  others,  to  give  him  ambition  to  shake  off  the  deadening 
effects  of  his  long  period  of  enforced  idleness,  and  to  under- 
take the  necessary  training  for  a  trade  or  occupation  from 
which  he  can  make  a  living. 

The  direction  of  his  treatment,  with  certain  medical  re- 
strictions, should  be  put  in  the  hands  of  an  officer,  trained 


Fig.  gg.  —  A  class  in  bookkeeping.     M.  H.  C.  Hospital,  Canada. 


in  vocational  guidance,  whose  knowledge  of  various  indus- 
tries and  the  training  necessary  for  them  would  be  brought 
into  service.  The  patient  should  be  examined  by  a  board, 
of  which  this  vocational  officer  is  a  member.  His  past  his- 
tory should  be  obtained  by  questions  about  the  kinds  of  work 
he  has  done,  his  stability,  as  shown  by  the  length  of  time 
he  has  held  jobs,  his  reasons  for  changing,  his  preferences 


108 


RECLAIMING   THE   MAIMED 


and  dislikes,  and  his  general  intelligence.  On  a  basis  of 
the  information  obtained,  combined  with  a  review  of  his 
medical  and  military  history,  he  should  be  advised  as  to  the 
work  best  suited  for  his  case.  He  would  then  register  for  the 
class  decided  upon  and  report  just  as  he  would  for  a  parade, 
and  he  must  be  kept  under  military  discipline,  for  his  own  sake. 


Fig.   ioo.  —  Mechanical  workshops  put  at  service  of  the  M.  H.  C.  by 
AIcGill  Universit^^  Montreal,  for  returned  soldiers. 


The  vocational  officer  must  have  instructors  in  charge  of 
each  branch  taught.  They  may  be  got  from  the  schools 
or  colleges  in  the  neighborhood,  or  in  some  cases,  they  may  be 
obtained  from  the  camp  or  hospital  itself.  They  must  be 
made  responsible  to  him  for  their  department,  and  carry  it 
on  under  his  direction.  The  courses  given  will,  of  necessity, 
vary  somewhat  with  local  conditions,  but  they  include : 


RECLAIMING    THE   MAIMED 


109 


1.  School  work.  The  preparation  of  students  for  civil 
service  examinations,  bookkeeping,  ofi&ce  work,  stenography, 
and  typewriting. 

2.  Draughting.  The  making  of  mechanical  and  ar- 
chitectural drawing  and  plans,  lettering  and  painting, .  and 
modeling  in  plasteline  or  clay. 


Fig.  ioi.  —  Repair  shop  for  automobiles.     M.  H.  C,  Canada. 

3.  Printing  and  bookbinding.  The  use  of  tools  and 
processes  of  binding  books,  lettering,  tool  work  on  leather, 
knotting  and  splicing,  th^  processes  of  printing,  and  lin- 
otype. 

4.  Woodwork.  The  use  of  tools  and  the  making  of  simple 
articles  in  wood,  going  on  to  making  apparatus  like  arti- 
ficial limbs,  toy  making,  cabinet  making,  and  allied  trades 
of  upholstery,  varnishing,  and  polishing. 


110 


RECLAIMING   THE  MAIMED 


5.  Mechanics.     The  use  of  tools  for  working  in  iron,  brass, 
and  tin.     Plumbing  and  steam  fitting. 

6.  Electricity.     Wiring  and  the  construction  and  repair 
of  electrical  apparatus. 

7.  Motors.     Driving  and  repairs  of  motor  cars. 


Fig.  102.  —  The  poultry  farmers  of  Alberta,  Canada. 

8.  Gardening.  Lectures  and  practice  in  the  care  of 
flowers  and  truck  gardens,  each  man  being  given  his  own 
patch  of  ground  to  cultivate. 

9.  Farming.  Lectures  and  practice  in  poultry  raising, 
beekeeping,  cheese  making,  dairy  and  general  farming,  and 
fruit  growing. 

Hospitals  should  be  affiliated  with  technical  schools  and 
colleges,  as  much  as  possible,  so  that  their  equipment  may 
be  employed  for  teaching  purposes.  In  this  way  expert 
teaching  is  easily  obtained,  and  the  necessity  of  extensive 
equipment  is  avoided.     For  small  institutions  this  is  not 


RECLAIMING    THE   MAIMED 


111 


always  possible,  and  a  standard  outfit  should  then  be  supplied 
for  each  trade  taught. 

If  the  experience  of  the  Canadian  authorities  may  be 
taken  as  a  guide,  less  than  ten  per  cent  of  all  men  require  re- 
education in  a  new  occupation.  The  majority  of  cases  that 
come   before    the   vocational    officer    suffer   from    medical, 


Fig.  103.  —  Wounded  Canadian  soldiers  returned  to  the  land. 

rather  than  surgical,  disabilities.  Rheumatism,  chronic  ne- 
phritis, neurasthenia,  and  tuberculosis  are  common,  some- 
times more  than  one  being  present. 

Every  case  must  be  considered  individually,  but  the  am- 
putations seem  to  form  a  class  by  themselves.  They  must 
first  be  trained  to  use  the  artificial  limbs  supplied  to  them 
by  the  hospital.  They  begin  with  the  use  of  a  sheath  for 
the  stump  and  exercises  with  pulley  weights,  to  strengthen 


112 


RECLAIMING   THE  MAIMED 


U 
U 


^ 

•m 


u 

O 


RECLAIMING    THE   MAIMED 


113 


the  weakened  musdes,  followed  by  practice  with  the  leg  or 
arm,  as  already  described.  The  artificial  hand  or  arm  issued 
will  depend  on  the  occupation  chosen.  Better  than  the 
"  Pince  Universelle "  of  Amar  or  the  German  '' Kellar 
Hook  "  is  the  cleverly  designed  "  Salary  Hook  "  or  clamp 


P'iG.  105.  —  Amar's  universal  pincer. 

issued  by  the  Canadian  government  for  heavy  work ;  the 
Dorrance  hook  is  valuable  for  light  work,  and  the  imitation 
hand  is  ornamental  for  Sunday.  The  Cams  arm  is  seldom 
used  except  by  an  expert.  When  the  trade  to  be  taught  is 
decided  upon,  he  begins  at  once  and  takes   an   increasing 


114 


RECLAIMING   THE  MAIMED 


RECLAIMING    THE   MAIMED 


115 


number  of  hours  per  day.  In  a  roll  kept  of  graduates  from 
Roehampton  and  the  London  Polyclinic,  legless  men  became 
electrical  workers,  moving  picture  operators,  telephone  work- 
ers, switchboard,  attendants,  motor  engineers,  munition 
workers,  carpenters,  clockmakers,  and  salesmen.  Armless 
men  became  electrical  workers,  switchboa_d  attendants,  car- 
penters, storekeepers,    laboratory   assistants.       The  legless 


Fig.  107.  —  Blind  Irish  Guardsman  at  work  as  a  masseur. 
Heaton  Park. 


men  averaged  in  wages  about  nine  dollars  a  week ;  and  the 
armless,  about  eight  dollars.  This  shows  the  results  of  the 
special  training  available  in  one  institution,  but  the  range  of 
instruction  can  be  infinitely  extended  for  both  armless  and 
legless  men. 

The  blind  have  naturally  received  sympathy  and  attention. 
Sir  Arthur  Pearson,  at  St.  Dunstans,  has  done  pioneer  work. 
They  can  be  taught  boot  repairing,  mat  making,  net  making, 


116  RECLAIMING   THE   MAIMED 

basketry,  simple  carpentry,  poultry  farming,  market  garden- 
ing, salesmanship,  and  massage.  The  use  of  the  dictaphone 
has  opened  typewriting  to  them,  and  there  is  little  difficulty 
in  obtaining  work  for  them. 

The  vocational  officer  must  be  familiar  with  the  prospects 
for  placing  men  in  their  chosen  occupations,  and  much  of 
his  work  will  be  in  this  field  through  employers  of  labor  and 
committees.  The  placing  of  men  whose  training  is  complete 
is  best  done  by  the  vocational  officer,  through  local  civilian 
committees.  Every  effort  must  be  made  to  induce  men  to 
undertake  and  follow  up  their  training,  by  both  rewards  and 
penalties.  The  American  government  has  organized  this 
part  of  the  reclamation  work  so  that  the  man  who  refuses 
to  take  any  form  of  training  may  have  his  pension  reduced, 
whereas  compliance  with  its  regulation  will  give  him  a  good 
living  in  addition  to  the  very  liberal  insurance  arrangements 
that  have  replaced  the  old  pension  system. 


CHAPTER  X 
MASKING   OF   FACIAL   DEFORMITY 

Among  the  most  distressing  cases  met  with  in  military 
surgery  are  those  in  which  the  face  has  been  so  destroyed 
as  to  defy  the  best  efforts  of  the  plastic  surgeon.  The  jagged 
fragment  of  a  bursting  shell  will  shear  off  a  nose,  an  ear,  or  a 
part  of  a  jaw,  leaving  the  victim  a  permanent  object  of  re- 
pulsion to  others,  and  a  grievous  burden  to  himself.  It  is 
not  to  be  wondered  at  that  such  men  become  victims  of  de- 
spondency, of  melancholia,  leading,  in  some  cases,  even  to 
suicide. 

After  plastic  surgery  has  done  its  best,  and  there  remains 
nothing  but  a  living  gargoyle,  much  may  still  be  done  to 
make  him  presentable  enough  to  mix  freely  with  his  fellows, 
and  to  earn  his  livelihood,  without  that  constant  humiliation 
to  which  his  appearance  would  subject  him. 

The  reclaiming  of  these  maimed  now  passes  out  of  the 
hands  of  the  surgeon  and  the  vocational  officer,  for  here  the 
sculptor  must  supplement  their  combined  efforts  by  his  skill 
in  modeling  masks  so  constructed,  colored,  and  attached  to 
the  face  as  to  successfully  hide  these  hideous  deformities. 
Many  mediums  have  been  tried ;  solid  rubber,  gutta  percha, 
papier  mache,  and  plaster ;  but  thin  copper  best  fulfills  the 
requirements,  being  pliable,  strong,  light,  and  durable.  The 
wound  must  be  soundly  healed,  so  that  no  further  shrinkage 
or  other  distortion  will  take  place,  before  starting  the  sculptor 
on  his  part  of  the  work. 

117 


118 


RECLAIMING    THE  MAIMED 


The  technique  to  be  followed  will  vary  slightly  with  the 
preference  of  the  operator.  Captain  Derwent  Wood,  A.R.A., 
whose  pioneer  work  in  this  branch  of  reconstruction  at  the 
3d  London  General  has  earned  such   well-deserved   praise, 

models  directly  on 
a  plasteline  base, 
although  such  a 
procedure  might  be 
disastrous  to  one  of 
less  experience.  The 
essentials  of  the 
technique  are  con- 
tained in  the  fol- 
lowing procedures. 

I.  The  deformed 
part  of  the  face, 
and  the  surround- 
ing regions  are  lubri- 
cated with  white 
vaseline,  taking  care 
to  fill  the  hair  spaces 
in  the  eyelids,  and 
the  eyelashes.  A 
quick-setting  plas- 
ter of  paris  is  mixed, 
and,  when  it  is  of 
the  consistency  of 
thick  cream,  it  is 
gently  painted  over  the  sound  tissue,  with  a  soft  brush, 
until  the  surface  is  covered.  Care  must  be  taken  to  leave 
a  breathing  space  at  the  nose  and  mouth,  and  to  see  that 
the  face  is  not  unnaturally  drawn  or  wrinkled  from  nervous- 
ness. The  plaster  is  strengthened  and  thickened,  until  it 
forms  a  sheet  about  one  inch  in  thickness.  When  this  has 
become  set,  as  shown  by  the  heat,  it  is  carefully  drawn  off. 


Fig.  108.  —  Destruction  of  the  face  from  the 

bridge  of  nose  to  the  lower  jaw. 
(Case  referred  to  author  by  Dr.  W.  L.  Clark.) 


RECLAIMING    THE   MAIMED 


119 


2.  This  mold,  or  negative,  is  well  soaped  with  green  soap, 
oiled,  and  a  cast,  or  positive,  is  made,  and  trimm.ed  to  the  re- 
quired shape  and  thickness.  This  serves  as  a  record,  or 
original  of  the  deformed  face.     Fig.  109. 

3.  From  this  model,  a  glue  mold,  or  negative,  is  made. 

4.  Several  casts  may  now  be  made  from  this  mold,  and 
colored  by  water  color,  to  match  the  plasteline,  which  is 
used  in  the  next 

process. 

5.  With  the 
patient  present, 
and  by  reference 
to  photographs, 
the  missing  nose 
is  modeled  on  one 
of  these  casts, 
great  care  being 
taken  to  imitate 
the  surrounding 
surface  texture 
and  match  it, 
especially  at  the 
edges.  It  is  safer 
to  model  this  in 
plasteline,  over 
the  plaster,  rather 
than  on  a  plaste- 
line squeeze,  as  described  later,  if  at  all  possible,  because 
the  hard  plaster  prevents  one  making  the  possible  error  of 
going  too  deep  in  modeling  a  hollow.  Where  a  missing  eye 
has  to  be  reproduced,  another  process  is  necessary  at  this 
stage. 

6.  A  piece  mold  must  be  made  from  the  cast  (4).  It  is 
prepared  with  French  chalk,  and  (6  A)  a  plasteline  squeeze 
made.    The  sculptor  then  opens  the  eye  by  modeling  it  from 


Fig.  109.  —  Cast  of  the  face  of  patient  in  Fig.  it 


120 


RECLAIMING   THE   MAIMED 


Fig.  iio. 


Wax  cast  of  remodeled  parts  in 
the  same  patient. 


life  (6  B),  because  the 
eye  was  closed  during 
the  taking  of  the  origi- 
nal mold  over  the  face. 

7.  A  glue  mold  must 
then  be  made,  from  this 
plasteline  cast  of  the 
remodeled  •  eye,  the 
sound  one,  and 

8.  A  cast  is  made 
from  this,  as  in  4,  the 
process  going  on  as  in  5. 

9.  When  the  missing 
features      have      been 

modeled  to  the  satisfaction  of  the  sculptor  and  the  patient, 
a  glue  mold  is  made  of  the  restored  face,  from  which 

10.  A  cast  in  wax  is  made  and  worked  on,  or  retouched,  if 
necessary.  Fig.  no. 

11.  The  wax  is  now  carefully  coated  with  bronze  powder, 
or  plumbago,  connected  by  copper  wire  with  the  cathode  of 
a  dry  cell  battery,  and  placed 
in  a  galvano  deposit  bath  of 
sulphuric  acid  and  sulphate 
of  copper,  between  two 
copper  plates  connected 
with  the  anode.  It  is  left 
there  until  a  film  of  copper 
one  thirty-second  of  an  inch 
in  thickness  is  deposited, 
a  process  lasting  four  or 
five  hours.  This  is  a  pro- 
cess in  which  many  failures 
are  likely  to  occur,  until  a 
good  deal  of  experience  is 
gained. 


Fig.  III.  —  Eye  and  socket  attached 
to  glasses,  showing  hinges  at  temple 
and  artificial  lashes.  Captain  Der- 
went  Wood. 


RECLAIMING    THE   MAIMED  121 

12.  The  wax  is  now  melted  out,  and  the  metal  mask 
trimmed  and  tried  on.  Every  advantage  must  be  taken  of 
natural  lines  and  wrinkles  of  the  face,  to  hide  the  borders. 
The  nostril  holes  are  opened,  as  well  as  the  eye  slit,  which 
masks  the  missing  eye. 

13.  The  mask  is  then  electroplated  with  silver  by  dipping 
in  a  solution  of  nitrate  of  silver,  and 

14.  When  the  eye  has  to  be  replaced,  the  artificial  glass 
eye  is  matched  with  the  good  eye,  or,  better  still,  a  blank  one 


Fig.  112.  —  Mask  for  Fig.  108,  colored  and  with  glasses  attached ; 
mustache  and  whiskers  in  place.     Patient  in  Fig.  108. 

is  painted  to  match,  and  then  placed,  and  held  in  place,  be- 
hind the  open  lids,  by  wire  clips,  like  the  setting  of  a  jewel  in 
a  ring.     This  fitting  requires  great  care  and  patience. 

15.  The  mask  is  now  given  a  coat  of  color,  and  the  com- 
plexion is  matched  with  great  care,  using  oil  colors  with  a 
wax  medium.  The  success  of  this  will  depend  entirely  upon 
the  artistic  skill  of  the  painter. 

16.  When  this  is  completed,  a  pair  of  spectacle  frames, 
with  heavy  rims,  are  fitted  on  over  the  mask,  and  the  nose 


122 


RECLAIMING    THE   MAIMED 


piece  is  riveted  through  the  copper,  or  soldered  to  hold  them 
in  place.  When  a  cheek  is  replaced,  it  may  be  necessary  to 
have  a  pin  from  the  spectacle  frame  to  the  mask,  to  give  the 
gentle  pressure  necessary  to  keep  it  in  place.     Fig.  112. 

17.   Eyebrows  can  be  made  with  real  hair,  or  by  painting 
them,  and  eyelashes  are  best  made,  in  the  experience  of 

Derwent  Wood,  of 
tin  foil,  cut  in  thin 
strips,  colored  and 
soldered  to  the  edge 
of  the  eyelid.  They 
can  also  be  set  with 
real  hair  in  a  groove 
of  the  lid,  and  held 
by  wax. 

When  any  dis- 
charge from  the 
eye,  nose,  or  sali- 
vary glands  is  pres- 
ent, dressings  can 
be  put  within  the 
mask,  and  renewed 
as  required,  for  the 
mask  is  put  on  and 
off  with  the  spec- 
tacles. In  some 
cases,  where  the 
lower  jaw  is  gone, 


Fig.  113.  —  Mask  in  place  on  patient  in  Fig.  io8. 


this  is  very  important,  because  the  saliva  is  constantly  drib- 
bling, and,  in  these  cases,  it  may  be  necessary  to  have  an 
additional  fastening  for  the  mask  about  the  neck.  Fig.  114. 
A  lost  ear  can  be  modeled  in  plasteline,  using  its  mate  for 
comparison,  and  the  process  continued  as  already  described, 
except  that  it  must  be  attached  by  spirit  gum  to  the  face,  as 
actors  do  with  false  whiskers,  taking  care  to  have  a  good 


RECLAIMING   THE   MAIMED 


123 


sized  bearing  surface.  The  mask  will  require  to  be  re- 
colored  from  time  to  time,  as  it  wears,  or  becomes  soiled,  but 
it  should  last  three  or  four  months,  with  reasonable  care, 
without  this  attention. 

The  illusion  should  be  complete  at  a  couple  of  yards'  dis- 
tance, except  that  where  an  eye  is  replaced,  it  cannot  close  and 
open,  and  a  squint  ap- 
pears, unless  the  patient 
takes  the  precaution  to 
look  his  friend   full  in 
the  face.     By  means  of 
these    masks,    horribly 
disfigured     men     have 
been  able  to  accept  and 
hold  positions  as  chauf- 
feurs,   elevator    attend- 
ants, clerks,  and,  in  fact, 
any   position   involving 
appearance  among  their 
fellows,   who   are   quite 
unconscious  of  the  grisly 
gap  present  beneath  this 
fair  exterior.     Timidity 
and      self-consciousness 
disappear,  as  they  find 
that  they  are  no  longer 
objects  of  repulsion  to 
every     onlooker.      Self- 
respect  returns,  depres- 
sion departs,  and  physical  health  follows  the  upward  trend 
of  their  spirits. 

The  process,  simple  as  it  may  sound,  is  really  rather  dif- 
ficult, and  can  only  be  brought  to  a  successful  result  by  a 
high  degree  of  sculptural  skill,  with  infinite  patience  in 
trimming  down^  building  up,  altering,  and  adapting;  with 


Fig.  1 14.  —  Loss  of  lower  part  of  face,  mask 
held  by  glasses  and  neck  ribbon.  Der- 
went  Wood. 


124 


RECLAIMING   THE   MAIMED 


many  failures,  before  these  strong  metal  films  will  conform 
to  the  remaining  parts  of  the  face,  both  in  form  and  texture. 
The  operator  who  is  not  a  sculptor,  and  a  sculptor  of  imagina- 
tion, at  that,  will  inevitably  fail. 


Fig.  115.  —  Loss  of  nose  with  mask  in  place.     Case  referred  to  the  author 
by  Dr.  W.  L.  Clark. 


INDEX 


Abdominal  congestions,  43 

Abrasions,  18 

Adhesions,  45,  5,  61,  62 

Aldershot,  95 

Amar's  universal  pincer,  113 

Amputations,  89,  90 

Ankle,  circumduction,  of  62 

treatment  of,  81 

stiff,  93 
Appliances,  mechanical,  66 
Arc  light,  37 

Architectural  drawing,  109 
Arm,  exercise  for,  gS 

lost,  93 
Armless  men,  vocations  for,  115 
Arthritis,  chronic,  21 
Artificial  eyebrows,  122 
Artificial  eyes,  121 
Artificial  hands,  113 
Artificial  limbs,  in,  89 

making  of,  169 
Artificial  masks,  117 

Back,  massage  of,  64 
Balance,  90 
Baths,  94 

cabinet,  100 

contrast,  51 

electric,  51 

hot,  SI,  49 

immersion,  53 

local,  50 

local  electric  light,  43 

medicated,  53 


Baths,  Schnee,  53 
whirlpool,  3,  50 
Bicycle  apparatus,  89 
Blinded  men,  vocations  for,  115 
Bookbinding,  109 
Bookkeeping  classes,  107 
Bullet  wounds,  3 
Bursitis,  22 

Card  system,  9 
Case  history,  9 
Cell,  galvanic,  11 

in  series  and  parallel,  13 
Chronic  pains,  22 
Circulation,  50,  56 
Circumduction,  62 

of  wrist,  74 
Claw  foot,  62 
Combined  currents,  31 
Command  Depots,  105 
Condenser,  32 
Contractures,  5 
Convalescent  camps,  105 

exercise  for,  95 


D.  A.  H.  Treatment,  7 
Dancing,  100 

Debility,  treatment  of,  7,  53 
Degeneration,  reaction  of,  27 
Diathermy,  33 
Disabled,  trades  for,  no 
Dorrance  hook,  113 
Douche,  47 
Dysentery,  95 

I2S 


126 


INDEX 


Effleurage,  54,  59 

Elbow,  flexion  and  extension  at,  77 
Electrical  treatment,  objects  of,  10 
Electricity,  93 

application,  20 

burns,  20 

static,  34 

units,  definition  of,  12 
Electrotonus,  17 
Endurance,  cultivation  of,  65 
Extension,  63 
Exercise  appliances,  73 

abdominal,  98 

after  dysentery,  95 

after  typhoid,  95 

Aldershot  tables,  97 

arm,  98 

armless  men,  93 

fit  for  duty,  92 

heart  cases,  94 

in  convalescent  camps,  95 

in  shell  shock,  94 

in  tuberculosis,  94 

leg,  98 

light  duty,  92 

mechanical,  98 

neck,  98 

unfit  for  duty,  92 
Exhaustion,  94 
Eyebrows,  artificial,  122 
Eyes,  artificial,  121 

Facial  deformity,  117 
Faradic  coil,  23 
Farming,  training  for,  no 
Fatigue,  50 
Fibrositis,  22 
Finger  board,  70 

machines,  70 
Finger  pulleys,  72 

treadmill,  73 
Flat  foot,  62 
Flexion,  62,  63 
Foot,  treatment  of,  82 


Foot,  exercise  for,  84 
Fractures,  59,  54 
Frost  bite,  21 

Galvanometer,  17 
Galvanic  battery,  14 

application  of,  18 

care,  of,  20 
Galvanic  current,  10 

effects  of,  15,  17,  21 

interruptions  of,  16 

reversal  of,  16 
Games,  99,  92,  loi 
Gardening,  training  for,  no 
Golf  course,  91 
Gymnastics,  92 

Hand,  lamp,  40 

newspaper  exercise  for,  79 
Hart  House,  68,  89 
Hearing,  loss  of,  5 
Heart  action,  93 

cases  exercise  for,  94 
Heaton  Park,  94,  99 
High  frequency,  32 
Hip,  massage  of,  63 

exercise  for,  86 

treatment  of,  82 
Hospitals,  exercise  for,  95 

Red  Cross,  105 
Hot  baths,  46 
Hydrotherapy,  field  of,  45 

Induction,  23 
Injured  nerves,  2 
Inspections,  93 

Intoxications,  treatment  of,  43 
Ionic  medication,  21 

Joint,  shoulder,  77 
Joints,  movements  of,  65 

reeducation  of,  68 

stiffened,  58 
Jones,  Sir  Robert,  63 


INDEX 


127 


Kellogg's  apparatus,  43 
Keogh,  Sir  Alfred,  105 
Knee,  flexion  of,  82 

massage  of,  63 

stiff,  93 

Legless  men,  vocations  for,  115 
Ley  den  jar,  32 
Limbless  men,  gi 
Lumbago,  22 
Lynn  Thomas,  91 

Masks,  artificial,  117 
Massage,  51,  54 

Mennell's  book  on,  59 

of  muscles,  65 

time  for,  60 
Mechanical  classes,  108 

workshop,  108 
Mechanics,  training  for,  no 
Measurements,  68 
Medical  switchboard,  31 
Melancholia,  117 
Mental  treatment,  5 
Molds  for  face,  119 
Motor  repairs,  training  for,  no 
Movements,  passive,  60 

active,  65 
Muscles,  massage  of,  65 
Myositis,  22 

Neck,  exercise  for,  98 

massage  of,  64 
Nerves,  injuries  to,  2,  45,  51 

degeneration  of,  27 

treatment  of  functional,  5 
Nervous  disturbance,  94 
Neuralgia,  39,  35 
Neurasthenia,  53 

treatment  of,  47 
Neuritis,  35 

Occupation,  treatment  by,  105 
Occupational  therapy,  106 


Pains,  referred,  39 

Paralysis,  51 

Passive  movement,  59,  60 

Pearson,  Sir  Arthur,  115 

Petrissage,  55 

Physical  therapy,  application  of,  2 

case  taking,  9 

plan  of  department,  7 

sequence  of,  7 
Post-operative  conditions,  5 
Primary  and  secondary  waves,  27 
Printing,  109 
Pronation,  62,  75 

Radiant  heat,  39 
Reeducation,  5,  65,  in 
Rest  room,  8 
Rheumatism,  22,  39,  56 
Rotation,  shoulder,  62 

Saint  Dunstan's  Hospital,  115 
Salary  hook,  113 
Scars,  58,  60,  59,  56,  54 

healed,  5 
Scar  tissue,  circulation  of,  39,  51 

treatment  of,  3 
Sciatica,  22 
Sculptor's  work,  117 
Septic  wounds,  5 
Shell  shock,  exercise  for,  94 

description  and  treatment,  6,  47 

electric  treatment  of,  35 
Shoulder,  treatment  of,  68 

flexion  and  extension,  77 

machines,  70 

rotation  of,  62,  77 

stretching  of,  78 
Sight,  loss  of,  5 
Sinusoidal  current,  16 
Speech,  loss  of,  5 
Sphygmomanometer,  69 
Sprains,  54 

treatment  of,  59 
Steam  compress,  43-44 


128 


INDEX 


Strength,  65 
Stumps,  5g,  89 

painful,  45,  51 
Supination,  62,  75 

Tapotement,  56 
Thennophore,  44 
Thigh,  exercise  for,  87 
Thumb,  exercises  for,  73 
Toy  making,  109 
Trades  for  disabled,  109 
Treatment  by  apparatus,  67 
Treatment  of  bullet  wounds,  3 
Trench  foot,  2 1 
Tuberculosis,  94,  112 

exrercise  for,  94 
Typhoid,  95 


Vibration,  57 

Vocational  training,  2,  106 

Vocations  for  armless  men,  115 

for  blind  men,  5 

for  legless  men,  115 

Whirlpool  bath,  action  of,  3 
Wood,  Capt.  Derwent  A.R.A.,  118 
Woodhead,   Lieutenant  Colonel  Sims, 

R.A.M.C,  105 
Wounds,  old  septic,  5 

shrapnel,  60 
Wrist,  movements  of,  74 

machines,  70 

Zander  machines,  66 


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A  Text-Book  of  Orthopaedic  Surgery 
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